Admission Date: [**2118-6-2**] Discharge Date: [**2118-6-14**]

Date of Birth: Sex: F

Service: MICU and then to [**Doctor Last Name **] Medicine

HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a history of emphysema DISEASE (not on home O2) who presents
with three days of shortness of breath DISEASE thought by her primary
care doctor to be a COPD DISEASE flare. Two days prior to admission
she was started on a prednisone taper and one day prior to
admission she required oxygen at home in order to maintain
oxygen saturation greater than 90%. She has also been on
levofloxacin and nebulizers and was not getting better and
presented to the [**Hospital1 18**] Emergency Room.

In the [**Hospital3 **] Emergency Room her oxygen saturation was
100% on CPAP. She was not able to be weaned off of this
despite nebulizer treatment and Solu-Medrol 125 mg IV x2.

Review of systems is negative for the following: Fevers
chills nausea vomiting DISEASE night sweats DISEASE change in weight
gastrointestinal complaints neurologic changes rashes DISEASE
palpitations orthopnea DISEASE . Is positive for the following:
Chest pressure occasionally with shortness of breath DISEASE with
exertion some shortness of breath DISEASE that is positionally
related but is improved with nebulizer treatment.

PAST MEDICAL HISTORY:
1. COPD DISEASE . Last pulmonary function tests in [**2117-11-3**]
demonstrated a FVC of 52% of predicted a FEV1 of 54% of
predicted a MMF of 23% of predicted and a FEV1:FVC ratio of
67% of predicted that does not improve with bronchodilator
treatment. The FVC however does significantly improve with
bronchodilator treatment consistent with her known reversible
air flow obstruction in addition to an underlying restrictive
ventilatory defect. The patient has never been on home
oxygen prior to this recent episode. She has never been on
steroid taper or been intubated in the past.
2. Lacunar CVA DISEASE . MRI of the head in [**2114-11-4**]
demonstrates Admission Date: [**2125-2-9**] Discharge Date: [**2125-2-16**]


Service: MEDICINE

Allergies DISEASE :
Zocor / Lescol

Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Chest pain DISEASE

Major Surgical or Invasive Procedure:
Central venous line insertion (right internal jugular vein)

History of Present Illness:
Mr. [**Known lastname 1858**] is an 84 yo man with moderate aortic stenosis DISEASE (outside
hospital echo in [**2124**] with [**Location (un) 109**] 1 cm2 gradient 28 mmHg moderate
mitral regurgitation DISEASE mild aortic insufficiency DISEASE ) chronic left
ventricular systolic heart failure DISEASE with EF 25-30% hypertension DISEASE
hyperlipidemia diabetes mellitus CAD DISEASE s/p CABG in [**2099**] with
SVG-LAD-Diagonal SVG-OM and SVG-RPDA-RPL with a re-do CABG in
[**9-/2117**] with LIMA-LAD SVG-OM SVG-diagonal and SVG-RCA. He also
has severe peripheral arterial disease DISEASE s/p peripheral bypass
surgery. He presented to [**Hospital 1474**] Hospital ER this morning with
shortness of breath and chest pain DISEASE and was found to be in heart failure DISEASE .

He states he was in his usual state of health until 10:30 last
evening when he woke up feeling coldAdmission Date: [**2119-5-12**] Discharge Date: [**2119-5-18**]

Date of Birth: [**2079-3-9**] Sex: M

Service: SURGERY

Allergies DISEASE :
Percocet / Lisinopril

Attending:[**First Name3 (LF) 301**]
Chief Complaint:
substernal chest pain DISEASE

Major Surgical or Invasive Procedure:
1. Closure of perforated ulcer DISEASE .
2. Partial gastrectomy.
3. Cholecystectomy.
4. Omental patch of ulcer DISEASE .


History of Present Illness:
40 M who is 2 years s/p laparoscopic RNY gastric bypass
presents to ED after transfer from [**Hospital6 302**] with a CT
scan showing pneumoperitoneum. Mr. [**Known lastname 303**] reports sudden onset
of substernal chest pain DISEASE at 5 am. Pain DISEASE was severe and his first
thought was that he was having an MI. Pain DISEASE unrelieved with
attempt at bowel movement. He denies fevers chills nausea DISEASE
vomiting DISEASE or any other symptoms. No radiation of the pain DISEASE .

Cardiac work-up at OSH was negative however abdominal CT showed
pneumoperitoneum. Pain DISEASE was relieved with dilaudid 4 hrs ago. He
currently denies abdominal pain DISEASE and feels much better.


Past Medical History:
HTN DISEASE
hypothyroidism DISEASE
back pain DISEASE w/sciatica
plantar fasciitis DISEASE

Social History:
He denied tobacco or recreational drug usage
has alcoholic beverages on rare occasions drinks iced coffee
and
diet soda several times per week. He is employed as a
laboratory
technologist in the chemistry lab at [**Hospital1 18**]. He is married
living
with his wife age 38 and they have one son age 6 months.


Family History:
His family history is noted
for father living age 75 with thyroid diseaseAdmission DISEASE Date: [**2160-8-4**] Discharge Date: [**2160-8-12**]

Date of Birth: [**2099-6-29**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Morphine

Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
Admission Date: [**2109-3-14**] Discharge Date: [**2109-4-3**]


Service: [**Hospital1 139**]

CHIEF COMPLAINT: Fevers.

HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old
female with a past medical history significant for Parkinson disease DISEASE with associated [**Last Name (un) 309**] body dementia DISEASE and a long history
of tobacco abuse DISEASE who was noted with fevers DISEASE .

The patient was in her usual state of health until two weeks
prior to admission when she developed rhinorrhea DISEASE . The
patient and her daughter deny any other symptoms at that
time.

However on the evening of [**2109-3-12**] the patient
reports that she developed pain DISEASE in the right side of her
neck. The following day she had a temperature to 101 with
continued intermittent right-sided neck pain DISEASE . She was again
febrile DISEASE on the morning of admission and called her primary
care physician for his advise. He suggested that she report
to the Emergency Department for further evaluation.

In the Emergency Department the patient's vital signs
revealed a temperature of 100 degrees Fahrenheit her heart
rate was 75 her blood pressure was 93/46 her respiratory
rate was 18 and her oxygen saturation was 96% on room air.

A chest x-ray in the Emergency Department showed consistent
cardiomegaly DISEASE . An opacity DISEASE in the right lower lobe with
probable right pleural effusion DISEASE was identified. There was no
pneumothorax DISEASE . The patient was started on levofloxacin for a
presumed community-acquired pneumonia DISEASE . Blood cultures were
obtained.

REVIEW OF SYSTEMS: On review of systems the patient reports
that she has Admission Date: [**2157-4-9**] Discharge Date: [**2157-4-18**]

Date of Birth: [**2106-1-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
vomiting DISEASE blood clots

Major Surgical or Invasive Procedure:
none

History of Present Illness:
50 yo M with h/o EtOH abuse and HTN DISEASE who presents with emesis DISEASE
with blood clots. Pt states he was vomiting DISEASE for 24 hours before
coming to the ED. States he last consumed EtOH 2 days PTA and
that he drank about a fifth of wine x 2. States he was sleeping
at the [**Hospital3 328**] and vomited again with red clots. Denies CP
SOB palpitations DISEASE F/C nausea DISEASE BRBPR. No black stools
constipation DISEASE or diarrhea DISEASE . No dysuria DISEASE .

Past Medical History:
EtOH abuse
HTN DISEASE
Admission Date: [**2157-5-11**] Discharge Date: [**2157-5-14**]

Date of Birth: [**2106-1-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
etoh withdrawal seizure DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
50 y/o male w/ h/o EtOH abuse UGI bleed DISEASE htn pancreatitis DISEASE
EtOH withdrawal sz presenting w/ EtOH intox and c/o abd pain DISEASE b/l
and nonspecific pain DISEASE Admission Date: [**2157-5-31**] Discharge Date: [**2157-6-1**]

Date of Birth: [**2106-1-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 338**]
Chief Complaint:
tremors nausea vomiting DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
50 y/o M w/ h/o ETOH abuse who p/w tremors tachycardia DISEASE
nausea vomiting DISEASE x 2 days. These symptoms started after he
stopped drinking ETOH 2 days prior to admission. He notes that
he threw up multiple times including a small amount of bright
red hematemesis DISEASE . He reports associated abdominal pain DISEASE and
tremulousness. Admission Date: [**2128-5-5**] Discharge Date: [**2128-5-7**]

Date of Birth: [**2067-10-12**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
right handed man with a history of long-standing seizure DISEASE
disorder DISEASE and a right frontal anaplastic ganglioglioma DISEASE with
oligodendroglioma DISEASE differentiation. He is status post
resection in [**2124-5-10**] and involved field cranial
irradiation. He had progressively deteriorated with
inability to walk being the most troublesome. He is no
longer able to get his left leg to move when standing and he
feels the left arm is also weaker and his speech is much
worse. His verbal responses are much slower and he has
significant word finding difficulty. The pain DISEASE in the left
leg at times is intense and the Morphine has helped with
this.

PHYSICAL EXAMINATION: On physical examination his blood
pressure was 118/70 pulse 60 respiratory rate 18. The
head eyes ears nose and throat is within normal limits.
The lungs are clear. The heart has regular rate and rhythm.
The abdomen is obese nontender. The extremities are without
edema DISEASE . Neurologically his speech is slower with word
finding difficulty and long pauses. His pupils are 4.0
millimeters and equally reactive to light. His visual fields
and extraocular movements DISEASE are full. Hearing is decreased in
the left ear. He has slight left facial droop DISEASE . The tongue
is midline. Palate rises symmetrically. There is a left arm
drift. Shoulder shrug is decreased on the left. The left
arm is 4Admission Date: [**2128-5-5**] Discharge Date: [**2128-5-7**]

Date of Birth: [**2067-10-12**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
right handed man with a history of long-standing seizure DISEASE
disorder DISEASE and a right frontal anaplastic ganglioglioma DISEASE with
oligodendroglioma DISEASE differentiation. He is status post
resection in [**2124-5-10**] and involved field cranial
irradiation. He had progressively deteriorated with
inability to walk being the most troublesome. He is no
longer able to get his left leg to move when standing and he
feels the left arm is also weaker and his speech is much
worse. His verbal responses are much slower and he has
significant word finding difficulty. The pain DISEASE in the left
leg at times is intense and the Morphine has helped with
this.

PHYSICAL EXAMINATION: On physical examination his blood
pressure was 118/70 pulse 60 respiratory rate 18. The
head eyes ears nose and throat is within normal limits.
The lungs are clear. The heart has regular rate and rhythm.
The abdomen is obese nontender. The extremities are without
edema DISEASE . Neurologically his speech is slower with word
finding difficulty and long pauses. His pupils are 4.0
millimeters and equally reactive to light. His visual fields
and extraocular movements DISEASE are full. Hearing is decreased in
the left ear. He has slight left facial droop DISEASE . The tongue
is midline. Palate rises symmetrically. There is a left arm
drift. Shoulder shrug is decreased on the left. The left
arm is 4Admission Date: [**2128-5-12**] Discharge Date: [**2128-5-18**]

Date of Birth: [**2067-10-12**] Sex: M

Service: #58

HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old
gentleman with a past medical history of a right frontal
antiplastic oligodendroglioma DISEASE status post resection in [**5-/2124**]
and 3/[**2128**]. He was just recently discharged from [**Hospital1 346**] after the most recent resection of
this tumor DISEASE and was sent to [**Hospital **] Rehab where he developed
a headache DISEASE . A CT scan showed postop changes without
excessive edema DISEASE or midline shift and the patient was sent
back to [**Hospital **] Rehab. Upon return he was noted to have
developed a fever DISEASE to 103 axillary and the patient was noted
to be more lethargic with mental status changes so he was
sent back to the Emergency Room for reevaluation.

PAST MEDICAL HISTORY: As above.

ALLERGIES: Percocet. The patient now reports a history of
itching red rash DISEASE from Percocet.

PHYSICAL EXAMINATION: Vital signs temperature 103.4
rectally. Blood pressure 170/86. Heart rate 84. Respiratory
rate 20. Sat 97% on 2 liters. HEENT the patient is status
post a right frontal craniotomy with moderate amount of
subgaleal DISEASE fluid collection which remains ballotable. Pupils
are equal round and reactive to light. He is sleepy but
arousable. He has short verbal communication and short
verbal responses to questions but no spontaneous speech.
His neck is mildly stiff with some nuchal rigidity DISEASE . The
chest has basilar crackles. Heart regular rate and rhythm.
Abdomen soft nontender nondistended. Positive bowel
sounds. Extremities no clubbing cyanosis DISEASE or edema DISEASE .
Neurological examination limited due to lethargy DISEASE . The patient
is arousable. He follows some commands inconsistently. He
moves all extremities but is noncompliant with strength
examination. Subgaleal fluid collection was tapped and sent
for culture. The patient also had an LP. Cerebral spinal
fluid was minimally cloudy and sent for cell count gram
stain and culture and sensitivity which grew out rare growth
staph coag negative. The patient has been treated with
intravenous antibiotics Vancomycin Ceftazidime 2 grams
intravenous q 8 hours times four weeks.

LABORATORIES ON ADMISSION: White blood cell count was 27.7
hematocrit 42.3 platelets 359 sodium 134 K 4.1 chloride
95 CO2 27 BUN 23 creatinine .9 glucose 99. His Depakote
level was 48 on admission. His urine was negative.

HOSPITAL COURSE: He was admitted for close observation to
the Surgical Intensive Care Unit. He was seen by the
Infections Disease DISEASE Service who recommended continuing the
Vancomycin and Ceftazidime and discontinuing Ceftriaxone for
antibiotic coverage. He was transferred to the floor on
hospital day number two. He was seen by physical therapy and
occupational therapy and found to require rehab prior to
discharge to home. He had PICC line placed for long term
antibiotics. His vital signs remained stable and he has been
afebrile throughout his hospital stay. His mental status he
is awake alert and oriented times three moving all
extremities strongly with good strength throughout. He has
been out of bed ambulating with physical therapy but still
requires some rehab before discharged to home. His PICC line
is in place and he will continue on Vancomycin Ceftazidime
for four weeks time and follow up with Infectious Disease DISEASE
Service and Dr. [**First Name (STitle) **] in three to four weeks time.

MEDICATIONS ON DISCHARGE: Lamictal 150 mg po q day Celexa
20 mg po q day at h.s. Zantac 150 mg po b.i.d. Decadron 2
mg po q 12 hours MS Contin 15 mg po b.i.d. Vancomycin 1
gram intravenous q 12 hours Ceftazidime 2 grams intravenous
q 8 hours Tylenol 650 po q 4 hours prn.

CONDITION ON DISCHARGE: Stable at the time of discharge.






[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**] M.D. [**MD Number(1) 343**]

Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36

D: [**2128-5-18**] 10:57
T: [**2128-5-18**] 11:16
JOB#: [**Job Number 347**]
Admission Date: [**2196-10-14**] Discharge Date: [**2196-10-18**]


Service: MEDICINE

Allergies DISEASE :
Hydrochlorothiazide

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Dizzyness

Major Surgical or Invasive Procedure:
Hypertonic saline infusion


History of Present Illness:
Mr. [**Known lastname 349**] is an 89 year old man who presented with several
months of dizziness thirst DISEASE and increased urination DISEASE . He was
confused and found to be hyponatremic DISEASE head CT negative CXR
clear UA negative. The patient is unable to recount a history
due to word finding difficulties. He is however alert and
oriented times three. When asked if there was someone to call to
get more information about him he responded that his sister
would be unable to help and he has no children as he was never
married.
.
ED course: Vitals: T 98 80 134/90 12 100% on RA DISEASE . He received
IVF 60 mEq of KCL and was free water restricted. 1L normal
saline over 3 hours.
.
On the floor the patient is confused but easily redirectable.
He is aware he is in the hospital and has no current complaints.



Past Medical History:
-HTN
-Hypercholesterolemia
-Unknown facial nerve condition - Admission Date: [**2126-7-29**] Discharge Date: [**2126-8-20**]

Date of Birth: [**2048-6-6**] Sex: F

Service: TRA


HISTORY OF PRESENT ILLNESS: Seventy-eight-year-old female
involved in a motor vehicle accident. She was an unrestrained
driver with no loss of consciousness DISEASE but was hit by a dump
truck with significant intrusion into the car. She has
complaint DISEASE of chest pain DISEASE and systolic blood pressure of 88 and
heart rate of 100 in the field.

PAST MEDICAL HISTORY: Amyloidosis depression kidney
stones.

PAST SURGICAL HISTORY: Breast implants 30 years ago tubal
ligation left hip replacement question of kidney stone DISEASE
surgery.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS: Prozac.

SOCIAL HISTORY: Two cigarettes per day 1-2 drinks per day.

PHYSICAL EXAMINATION: Temperature was 99.4 heart rate 92
blood pressure 115/40 respiratory rate 20 and 94% on face
mask. She has a GCS DISEASE of 15. Pupils were equal and reactive.
Trachea was midline. Heart was regular rate and rhythm.
Abdomen was soft nontender nondistended. There was gross
hematuria DISEASE visible. The pelvis was stable but slightly
tender. Rectal was guaiac negative. Back had some abrasions
but no step-offs. There were some abrasions of the
extremities but no gross deformity.

LABS: White blood cell count is 12.6 hematocrit 24.9
platelets 241. Chem-7 with a sodium of 142 potassium 4.0
chloride 110 bicarbonate 19 BUN 39 creatinine 1.3 glucose
114. Amylase is 133. Toxicology screen was negative.

Head CT was negative.

C. spine CT shows C2 fracture DISEASE through the transverse foramen
bilaterally.

Chest CT showed bilateral small pneumothoraces DISEASE with bilateral
rib fractures DISEASE bilateral pulmonary contusions DISEASE .

Abdomen and pelvis CT showed a splenic laceration DISEASE with no
free fluid blood in the left renal pelvis with blood in the
ureter. There is a small liver laceration DISEASE and a sacral
fracture DISEASE as well as left iliac [**Doctor First Name 362**] small fracture DISEASE .

HOSPITAL COURSE: Patient was admitted to the trauma DISEASE
intensive care unit for close observation. Patient was seen
by the [**Doctor First Name **] service and was recommended to have a
nephrostomy tube placed which was done. There was difficulty
with the initial nephrostomy tube and interventional
radiology inserted the nephrostomy tube.

Patient was seen by the thoracic surgery service for the
bilateral pneumothoraces DISEASE . Chest tubes were attempted but
unable to be passed due to scarring and the lungs cleared.
Patient was seen by the orthopedic spine service as well. It
was determined that the C2 fracture DISEASE would require a hard
collar for at least 8-12 weeks.

Patient was in the trauma DISEASE intensive care unit with
hematocrits being followed serially. On the evening of
[**8-2**] patient's serial hematocrits were significantly
altered. Patient dropped her blood pressure became
hemodynamically stable and the hematocrit was in the mid
teen's. It was decided at this time patient will be brought
to the emergency room emergently to have an open splenectomy.

Postoperatively the patient was again brought to the trauma DISEASE
intensive care unit. We gradually weaned the patient from the
ventilator over the course of the next 15-20 days. Patient
had some sputum samples which revealed some gram-negative
rods for which she was started on levofloxacin. A 14-day
course of that was to be initiated. Patient was started on
nutrition with ProMod with fiber by Dobbhoff feeding tube. A
percutaneous tracheostomy was performed on [**8-9**]
successfully.

On the last few days in the intensive care unit patient was
able to wean to a tracheostomy collar. This was tolerated
well. Speech and swallow was done the day of discharge which
a Passy-Muir valve was not tolerated for extended periods of
time. However it was felt in due time patient would be able
to swallow on her own in a relatively short period of time.

CONDITION ON DISCHARGE: Stable.

DISCHARGE STATUS: Extended care facility.

DISCHARGE DIAGNOSIS: Status post splenectomy.

DISCHARGE MEDICATIONS: Listed on but they consistent of
acetaminophen 325 mg p.o. q.4-6h. p.r.n. fluoxetine 20 mg
daily insulin sliding scale albuterol nebulizer 1-2 puffs
q.6h. p.r.n. Artificial Tears 1-2 drops both eyes p.r.n.
Artificial Tears ointment 1 both eyes p.r.n. aspirin 325
daily Dulcolax 10 mg p.r./p.o. p.r.n. daily Diazepam 5 mg
p.o. q.12h. p.r.n. Colace 100 mg p.o. b.i.d. Lovenox 40 mg
subcutaneously daily Prevacid 30 mg p.o. daily levofloxacin
500 mg p.o. q.24h DISEASE . for 3 more days Lopressor 25 mg p.o.
daily and oxycodone liquid 5-10 mg p.o. q.4h. p.r.n. pain DISEASE .

FOLLOW UP: Patient will follow up with Dr. [**Last Name (STitle) 363**] from
orthopedic Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 364**] [**Name5 (PTitle) **] service Dr. [**Last Name (STitle) 365**]
in approximately 2 weeks and the trauma DISEASE clinic in
approximately 2 weeks.



[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**] [**MD Number(1) 367**]

Dictated By:[**Name8 (MD) 368**]
MEDQUIST36
D: [**2126-8-20**] 11:13:44
T: [**2126-8-20**] 11:48:24
Job#: [**Job Number 369**]

cc:[**Hospital1 370**]Admission Date: [**2192-4-19**] Discharge Date: [**2192-5-23**]


Service: MEDICINE

Allergies DISEASE :
Lisinopril

Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
Diarrhea DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mrs. [**Known lastname **] is an 84 yo f h/o CRI HTN DISEASE GERD colon ca
neprhotic syndrome dc'd [**3-31**] after low anterior resection of
colon. Now p/w 1wk h/o diarrhea DISEASE worsened one day prior to
admission found to have wbcc 30 in ED admitted [**4-19**] and
started on both p.o. vanco and IV flagyl. Began to have brbpr on
[**4-25**] on [**4-30**] had flex sigmoidoscopy showing pseudomembranes DISEASE with
recurrent c.diff vs. bowel ischemia as etiology. Then developed
some sob/fluid overload DISEASE and was started on lasix and neseritide
gtt's. Had had some intermittent afib which was thought to be
contributing to presumed diastolic dysfunction DISEASE . Tx to CCU
[**2192-5-12**] for worsening tachypnea DISEASE and oliguria DISEASE on nesiritide and
lasix gtt. Was cardioverted chemically with good result. Also
developed acute on chronic renal failure DISEASE for which nephrology
has been following zenith of 6.0 now back at baseline
creatinine of 2.0's.


Past Medical History:
Recent admission to [**Hospital1 18**] from [**2192-2-17**] to [**2192-2-29**] for treatment
of likely viral gastroenteritis DISEASE PNA transaminitis DISEASE discharged
to [**Hospital **] Rehab in [**Hospital1 8**]

- RAS: MRI ([**2185**]) atrophic R kidney mod stenosis of R renal artery L renal artery DISEASE normal
- CRI/nephrotic range proteinuria DISEASE : [**2191**] baseline Cr 2.5Admission Date: [**2126-8-23**] Discharge Date: [**2126-9-19**]

Date of Birth: [**2048-6-6**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
HISTORY OF PRESENT ILLNESS: Seventy-eight-year-old female
involved in a motor vehicle accident. She was an unrestrained
driver with no loss of consciousness DISEASE but was hit by a dump
truck with significant intrusion into the car. She has
complaint DISEASE of chest pain DISEASE and systolic blood pressure of 88 and
heart rate of 100 in the field.
78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p
trach/spenic lac s/p splenectomy/pelvic fx) - from rehab septic DISEASE
picture likely aspiration pneumonia DISEASE secondary to dobhoff being
placed into lung.

Major Surgical or Invasive Procedure:
placement of G tube

History of Present Illness:
HISTORY OF PRESENT ILLNESS:78F re-admit (s/p MVC with c spine
fx/pulm contusions/rib fx s/p trach/spenic lac s/p
splenectomy/pelvic fx) - from rehab septic DISEASE picture likely
aspiration pneumonia DISEASE secondary to dobhoff being placed into
lung. Seventy-eight-year-old female
involved in a motor vehicle accident. She was an unrestrained
driver with no loss of consciousness DISEASE but was hit by a dump
truck with significant intrusion into the car. She has
complaint DISEASE of chest pain DISEASE and systolic blood pressure of 88 and
heart rate of 100 in the field.admitted to [**Hospital1 18**] on [**7-29**] with C2
fracture DISEASE bilateral pleural
hematomas DISEASE L breast implant rupture DISEASE rib fractures DISEASE splenic
laceration s/p splenectomy and s/p nephrostomy tube placement
who returned to [**Hospital1 18**] from rehab on [**8-23**] with hypoxia DISEASE and
respiratory distress DISEASE .


Past Medical History:
PMH:
Amyloidosis depression kidney stones DISEASE hx of tubal ligation L
hip replacement

Social History:
SH: 2 cigs per day 1-2 drinks per day

Family History:
FH DISEASE : daughter [**Name (NI) 372**] is currently undergoing temporary
guardianship

Physical Exam:
Tc afebrile HR 96 BP 161/67 RR 34 99% on PS
[**7-5**] 40% FI02

Gen: lying in bed eyes open minimal mvmt.
HEENT: trach in place copious sputum out of trach opening
coughingmmm OP benign
Neck: in C collar
CV: RRR difficult to auscultate given breath sounds
Resp: coarse upper airway sounds bilaterally
Abd: multiple dressings covering postop incisions ileostomy bag

c/d/i
Ext: warm well perfused
Skin: ecchymoses on legs and arms.
MS: Awake opens eyes to voice but not command and looks to
right
at calling of name not consistently to left. Wiggles toes to
commands will not squeeze hands to command will not lift arms
to command.
CN: PERRLA blinks to threat bilaterally. Full eye movements
horizontally but seems to have R gaze preference. No evidence of

nystagmus DISEASE no ptosis DISEASE . Grimaces to stim on both sides of face.
Corneal reflex present. Face symmetric but difficult to assess
wtih collar. Hears voice. No speech. Admission Date: [**2137-3-7**] Discharge Date: [**2137-3-16**]

Date of Birth: [**2060-10-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Lisinopril

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Acute renal failure DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
76 yo male w/PMHx sx for chronic kidney disease cirrhosis DISEASE [**1-31**]
NASH DISEASE vs. PSC with resultant ascites DISEASE and Grade II esophageal
varices DM2 DISEASE PSC and CAD who presents with acute worsening of
creatinine. Patient has chronic kidney disease DISEASE with baseline
creatinine of 1.8 now elevated to 4.8 with potassium 5.8. His
CKD DISEASE is thought [**1-31**] HTN DISEASE and DM2 DISEASE . He recently received therapeutic
paracentesis with removal of 3.5L of fluid negative for SBP. He
states that he has noticed increasing abdominal distension DISEASE and
fatigue DISEASE over the past several weeks. He has not noticed
increased pruritus confusion DISEASE delta MS.
.
He has taken recent antibiotics and states that his po intake
has been poor due to lack of appetite. He says that his urine
output has been about the same as prior. Denies use of NSAIDS at
home. He has not been able to walk long distances because of his
LE swelling DISEASE . Denies CP/SOB/DOE/F/C/N/V/BRBPR/melena DISEASE .


Past Medical History:
1) Right Popliteal DVT DISEASE . (s/p IVC filter)
2) DM type 2Admission Date: [**2167-10-20**] Discharge Date: [**2167-10-27**]

Date of Birth: [**2098-7-31**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Macrodantin / Sulfonamides / Compazine / Atorvastatin /
Lovastatin / Metoprolol

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Transfer for respiratory failure DISEASE

Major Surgical or Invasive Procedure:
PA catheter placement

History of Present Illness:
Ms. [**Name14 (STitle) 399**] is a 69 year-old female with a history of
diabetes coronary artery disease COPD DISEASE who presents on transfer
for respiratory distress DISEASE .
.
Per review of OSH records: Patient presented to OSH with
complaints of [**2-7**] days of cough DISEASE and dyspnea DISEASE . On the day prior
to transfer she ws out in public and experienced a sudden onset
of worsened dyspnea DISEASE . She asked bystanders to call EMS and by
the time they arrived she was found unresponsiveAdmission Date: [**2143-4-1**] Discharge Date: [**2143-4-5**]

Date of Birth: [**2095-2-27**] Sex: F

Service: Cardiothoracic Surgery

CHIEF COMPLAINT/REASON FOR ADMISSION: Ms. [**Known firstname **] [**Known lastname 403**] is
a postoperative admission who was admitted directly to the
operating room for mitral valve repair versus replacement.
She was seen in preadmission testing prior to surgery. At
that time her chief complaint DISEASE was occasional dyspnea DISEASE on
exertion.

HISTORY OF PRESENT ILLNESS: This is a 47-year-old woman with
known mitral regurgitation DISEASE followed by electrocardiogram.
Cardiac catheterization done showed 3 to 4Admission Date: [**2174-6-19**] Discharge Date: [**2174-7-4**]

Date of Birth: [**2093-11-17**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Atorvastatin

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Transesophageal echocardiogram
Esophagogastroduodenoscopy


History of Present Illness:
Ms. [**Known lastname 426**] is an 80yo woman with h/o CAD s/p recent PCI severe
AS s/p valvuloplasty [**4-/2174**] and recently treated for possible
pneumonia DISEASE with ceftazidime [**Date range (1) 427**] admitted with shortness of breath DISEASE and hypotension DISEASE .

Ms. [**Known lastname 428**] husband reports that he has observed her breathing
very fast around 3 or 4 in the morning for the last couple of
nights. On the day of admissin she woke up short of breath and
breathing quickly. He used a stethoscope (which he has to help
with home maintenance) and heard a hissing/wheezing on her right
chest which prompted him to call 911. She continued breathing
fast until she was intubated in the ED with her consent. He
notes that she has had a minimally productive cough DISEASE since her
last admission though she has not had fevers DISEASE or chills DISEASE . She
had diarrhea DISEASE for about a day recently but this has resolved.
Her nephrologist contact[**Name (NI) **] her on [**6-16**] and advised her to
decrease her lasix from 160mg daily to 80mg because of her
rising creatinine. Despite this change her daily weight has
remained stable at 119-120 pounds. She has been compliant with
1L fluid restriction.

In the ED her initial VS were: 99.8 115 122/75 30s 82%
NRB. She was noted to have crackles on her pulmonary exam. She
was given rocuronium etomidate and versed and intubated
urgently. Shortly after propofol gtt was started she dropped
her pressures into the into the 70s (per reportAdmission Date: [**2174-7-17**] Discharge Date: [**2174-7-20**]

Date of Birth: [**2093-11-17**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Atorvastatin

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Transfused 2 units PRBC.

History of Present Illness:
This is a 80yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**]
and recent aortic valvuloplasty [**2174-5-11**] recently hospitalized
for CHF DISEASE exacerbation requiring intubation(d/c [**2174-7-4**]) who
returns w/SOB x several hours. She notes that she had been
feeling well since her d/c home until this AM. She awoke at 0300
feeling well but then began to get aggravated thinking about
recent political issues and started to feel SOB as she sat in
bed. Endorses slow onset SOB that persisted causing her and her
husband to call EMS. She received one dose of IV lasix 100mg en
route to the ED to which she put out 100cc DISEASE of urine. She
endorses having had cough DISEASE w/sputum production 2 days PTA but
denies recent fever/chills.
.
In the ED her initial VS were: 96.4 174/82 HR 109 RR 30s sat
85% 10LNRB. She was briefly on CPAP 5/5 and O2 sat increased to
100%. She was also briefly on a Nitroglycerin drip for her
BP(1hour). She received Aspirin Furosemide 180mg IV x1 as well
as Vancomycin 1g and Piperacillin-Tazobactam for her
leukocytosis DISEASE .
.
She and her husband endorse that she has been adherent with her
medications and her 2g sodium diet w/1200-1500 fluid
restriction. They note that her daily weight has been very close
to her dry weight of 109lbs w/just one higher weight last week
of 109.5lbs. She denies chest pain DISEASE ankle edema palpitations DISEASE
syncope DISEASE or presyncope DISEASE . Admission Date: [**2174-7-22**] Discharge Date: [**2174-8-5**]

Date of Birth: [**2093-11-17**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Atorvastatin

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
upper endoscopy dialysis


History of Present Illness:
This is a 80yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**]

and recent aortic valvuloplasty [**2174-5-11**] s/p multiple
hospitalizations for CHF DISEASE exacerbation (last d/c [**2174-7-20**]) who
returns w/SOB x several hours. Her husband noted that she went
home feeling well. She was breathing comfortably w/o any
episodes of CP/palpitations/SOB. This AM Admission Date: [**2174-8-6**] Discharge Date: [**2174-8-12**]

Date of Birth: [**2093-11-17**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Atorvastatin

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Dialysis


History of Present Illness:
Pt is a 80 yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**]
severe aortic stenosis DISEASE with valvular area of 0.5 cm2 despite
recent aortic valvuloplasty on [**2174-5-11**] frequent
hospitalizations for CHF DISEASE exacerbation (last d/c [**2174-8-5**]) and
ESRD DISEASE recently restarted on HD who returns w/SOB. She was
admitted on [**2174-7-22**] for CHF DISEASE exacerbation and discharged
yesterday. She was initally treated with Lasix went into
worsening renal failure DISEASE and started on hemodialysis. Her course
was also complicated by upper GI bleed of which an EGD showed
multiple AVMs. She required total of 5 units of PRBCs and by
discharge HCT was stable at 26. She received her last
transfusion yesterday at HD.
Pt was discharged to rehab. She ate well for dinner under 2 gm
of sodium diet. She report feeling warm the evening prior to
admission but was afebrile. She still felt warm and diaphoretic
this morning. Again she was afebrile per her husband. She did
have increased productive cough DISEASE with mostly clear occasionally
blood-tinged phlegm DISEASE . She then became acutely short of breath
while lying down. She denied any CP palpitations nausea DISEASE
vomiting DISEASE . She asked to return to the hospital.
.
In the ED her initial VS were: T98 BP 150/80 HR 130 RR 42
O2 sat 92% on Admission Date: [**2141-8-16**] Discharge Date: [**2141-8-24**]

Date of Birth: [**2070-10-21**] Sex: F

Service: SURGERY

Allergies DISEASE :
Hydrochlorothiazide / Zoloft

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatic Head Mass / CBD Mass

Major Surgical or Invasive Procedure:
Pylorus-Preserving Whipple Procedure
Open Cholecystectomy
Primary Incisional Hernia DISEASE Repair


History of Present Illness:
This is a 70 year old female with a history of ovarian cancer DISEASE
now with 2 weeks of painless jaundice DISEASE dark urine acholic
stools and she was found to have a distal CBD/pancreatic head
mass on CT and ERCP.

Past Medical History:
PMHx: ovarian CA HTN DISEASE high chol AAA (3.5 cm) OA DISEASE CRI (CR 1.5)
PSHx: TAH/BSO [**2126**]Admission Date: [**2143-4-20**] Discharge Date: [**2143-4-26**]

Date of Birth: [**2070-10-21**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Hydrochlorothiazide / Zoloft / Compazine

Attending:[**First Name3 (LF) 492**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
L thoracotomy with pericardial window and chest tube placement

History of Present Illness:
72 W from [**First Name8 (NamePattern2) 466**] [**Country 467**] with multiple cancers DISEASE including ovarian
(s/p s/p TAH SBO and 6 cycles of ctaxol/carboplatinium) and
cholangiocarcinoma DISEASE (s/p whipple) with mets DISEASE of uncertain origin
to liver and lung DISEASE recently admitted [**4-6**]-22 for CAP
(treated with azithro) originally admitted to [**Hospital Unit Name 153**] for SOB
orthopnea DISEASE and coughing which was initially attributed to CHF DISEASE
symptomatic hyponatremia DISEASE (increasing confusion DISEASE lethary) and
ARF DISEASE . Cards was consulted and an echocardiogram revealed a
pericardial fluid collection with tamponade DISEASE . She was sent
urgently to the OR for a pericardial window via L thoracotomy.
She was out of the OR by [**8-28**] PM extubated by 0400 the day of
transfer and seemed to be doing well. She was sitting up in a
chair when she was noticed to be unresponsive but still
breathing and with a pulse. She was transferred back to her bed
and at that ppint was noticed to be in full cardiac and
respiratory arrest DISEASE without pulse or spontaneous respirations.
Patient did have a rhythm on monitor so patient was diagnosed
with PEA arrest DISEASE . CPR was initiated she received 2 amps of epi
and an an of calium she was intubated started on Neo and had
a femoral line placed. Within 15 minutes pulse returned. A
stat repeat ECHO was performed at that time and patient was
found to have [**Male First Name (un) **] (systolic anterior motion) severe MR DISEASE and new
wall motion abnormalities DISEASE but no re-accumulation of pericardial
effusion. She is now being transferred to the MICU for further
work-up and management.

Past Medical History:
Pancreatic cancer DISEASE s/p whipple [**2141-7-18**] metastatic to liver
Ovarian ca s/p carboplatinum/taxol ([**2126**])
HTN DISEASE
AAA
OA DISEASE
Depression DISEASE
Vertigo DISEASE


Social History:
Occupation: former storekeeper in [**First Name8 (NamePattern2) 466**] [**Country 467**] moved to US in
[**2134**] after husband disappeared during their pilgrimage to [**Location (un) 481**]
in [**2133**]
Drugs: None
Tobacco: None
Alcohol: None


Family History:
NC

Physical Exam:
General Appearance: Thin
Eyes / Conjunctiva: PERRL Conjunctiva pale
Head Ears Nose Throat: Normocephalic dry MM
Lymphatic: Cervical LAD
Cardiovascular: (PMI Normal) (S1: Normal) (S2: Normal)
(Murmur: [**1-23**] soft Systolic Ejection Murmur)
Peripheral Vascular: (Right radial pulse: Present) (Left radial
pulse: Present) (Right DP pulse: Present) (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric) (Breath Sounds:
Crackles : [**12-19**] way up bilaterally)
Abdominal: Soft Non-tender No bowel sounds DISEASE present nontender
palpaple mass DISEASE in epigastrium
Extremities: Right: 2Admission Date: [**2143-4-25**] Discharge Date: [**2143-4-30**]

Date of Birth: [**2076-8-18**] Sex: M

Service: Cardiac Surgery

CHIEF COMPLAINT: Chest pain DISEASE 3-vessel disease on
catheterization.

HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
male transferred from [**Hospital6 33**] to the [**Hospital1 346**] status post catheterization
revealing 3-vessel cardiac disease DISEASE .

The patient presented to [**Hospital6 33**] with gradually
increasing chest pain DISEASE over the past three to four months to
the point that he had chest pain DISEASE with minimal exertion.

PAST MEDICAL HISTORY:
1. Known coronary artery disease DISEASE status post
catheterization 10 years ago at [**Hospital1 **].
2. Heavy smoker.
3. Hypertension DISEASE .
4. Gastroesophageal reflux disease/peptic ulcer disease DISEASE .
5. Wegener granulomatosis DISEASE with complete resolution.
6. Glaucoma.

PAST SURGICAL HISTORY: Perforated ulcer DISEASE .

MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d.
Prilosec 20 mg p.o. q.d. Cosopt eyedrops Alphagan eyedrops
Travatan eyedrops lansoprazole 50 mg p.o. q.d.

ALLERGIES: No known drug allergies DISEASE .

HOSPITAL COURSE: The patient underwent an elective coronary
artery bypass graft times three on [**2143-4-26**] with grafts
being a left internal mammary artery to left anterior
descending artery saphenous vein graft to ramus and
saphenous vein graft to posterior descending artery. He was
extubated on the day of surgery. On postoperative day one
his nasogastric tubes were discontinued.

He was transferred to the regular floor on postoperative day
one. He subsequently had a smooth postoperative course. His
pacing wires were discontinued on postoperative day three.

By postoperative day he was ambulating well. He was
comfortable on p.o. pain DISEASE medication and he was ready for
discharge home.

MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. q.d. (for one week).
2. KCL 20 mEq p.o. q.d. (for one week).
3. Colace 100 mg p.o. b.i.d.
4. Zantac 150 mg p.o. b.i.d.
5. Enteric-coated aspirin 325 mg p.o. q.d.
6. Alphagan eyedrops.
7. Lopressor 50 mg p.o. b.i.d.
8. Nicoderm patch 22 mg q.d.
9. Percocet one to two tablets p.o. q.4-6h. p.r.n.

DI[**Last Name (STitle) 408**]E FOLLOWUP: Follow up with primary care physician
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2208**] in two weeks and with Dr. [**Last Name (Prefixes) **] in
four weeks.

CONDITION AT DISCHARGE: Condition on discharge was stable.

DISCHARGE STATUS: Discharged to home.




[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]

Dictated By:[**Last Name (NamePattern1) 2209**]

MEDQUIST36

D: [**2143-4-30**] 15:09
T: [**2143-4-30**] 15:31
JOB#: [**Job Number 2210**]
Admission Date: [**2189-9-7**] Discharge Date: [**2189-9-9**]

Date of Birth: [**2129-3-28**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Lomotil

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Pyelonephritis DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Ms. [**Known lastname 496**] is a 60 yo F with hx of chronic hepatitis C who
presents to the ED with dysuria DISEASE x 4 days chills nausea DISEASE and
vomiting DISEASE . She first noted hematuria DISEASE on Saturday then developed
dysuria DISEASE urinary frequency urgency and incontinence DISEASE . Admission Date: [**2112-6-6**] Discharge Date: [**2112-6-14**]


Service: GENERAL SURGERY

HISTORY OF PRESENT ILLNESS: On [**2112-6-5**] the patient had a
sudden onset of emesis DISEASE in the morning with no associated
nausea abdominal pain DISEASE or change in bowel habits and is
passing flatus. She also passed brown stool that day. She
has had no signs of fevers DISEASE or chills DISEASE or sick contacts or
recent travel. Twenty years ago the patient had a similar
episode and by history she was told she had a gallbladder
problem but she never had any treatment given. She
presented to the Emergency Department with a fever DISEASE of 104.4
and mildly tender right upper quadrant with negative [**Doctor Last Name 515**]
sign. An ultrasound demonstrated multiple gallbladder stones
and a 1.4 cm stone in a 1.5 cm common bile duct. No
intrahepatic ductal dilatation or gallbladder wall thickening DISEASE
or pericholecystic fluid. The patient received Levofloxacin
and Flagyl and was urgently seen by the ERCP fellow and taken
for endoscopic retrograde cholangiopancreatography which
demonstrated some gastritis DISEASE and severely deformed major
papilla and 8 mm common bile duct with no stones and a
sphincterotomy was performed with drainage of clear bile.
The patient was then admitted to the Medical Service.

PAST MEDICAL HISTORY: 1. Hypertension. 2. Breast cancer DISEASE
status post lumpectomy in [**2103**]. 3. Hypercholesterolemia.
4. Diabetes mellitus DISEASE type 2. 5. Hypothyroidism status post
thyroidectomy. 6. Left cataract DISEASE surgery corneal
transplant. 7. Pernicious anemia DISEASE . 8. Stress incontinence DISEASE .
9. Appendectomy.

ALLERGIES: Bactrim.

MEDICATIONS: 1. Atenolol 50 mg po q day. 2. Glyburide.
3. Mavic one time per day. 4. Synthroid 150 mg po q day.
5. Lipitor 10 mg po q day. 6. Aspirin 81 mg po q day. 7.
Apraclonidine 0.5% one drop OS b.i.d. 8. Timolol maleate
0.5% one drop OS b.i.d. 9. Prednisolone acetate one drop OS
t.i.d.

SOCIAL HISTORY: The is a Russian immigrant who taught
English. The patient does not use tobacco or alcohol.

PHYSICAL EXAMINATION: The patient had a temperature of
100.6 heart rate of 62 blood pressure 153/60 respiratory
rate 22 saturation 92% on room air. Pertinent physical
examination demonstrated a soft mildly tender right upper
quadrant with no [**Doctor Last Name **] sign. Normal rectal tone and guaiac
negative.

PERTINENT LABORATORY INFORMATION: White blood cell count
4.4 PT 13.7 INR 1.3 total bilirubin was 0.4 ALT 34 AST
24 alkaline phosphatase 106. Urinalysis negative.

HOSPITAL COURSE: The patient was managed medically until the
[**4-10**] because the patient was refusing
cholecystectomy as was recommended. However on the [**4-10**] the patient was amenable to surgery because of
persistent right upper quadrant soreness. On [**6-10**] the
patient underwent an open cholecystectomy with a common bile
duct exploration and placement of T tube and intraoperative
cholangiogram. The patient had some difficulty with
extubation because of sedation and was transferred from the
[**Hospital Ward Name 516**] at [**Hospital1 69**] to the
[**Hospital Ward Name 517**] in the Surgical Intensive Care Unit. The
following day on postoperative day one the patient was
extubated after being weaned off her Propofol without any
complications and was maintained NPO. The patient remained
well throughout the afternoon in the Surgical Intensive Care
Unit and was transferred to the floor.

On the floor the patient did well. Physical therapy consult
was acquired where she performed well but was recommended
for rehabilitation. She began tolerating clears and a
regular diet. She remained afebrile and she had her Foley
discontinued. The patient had her JP tube discontinued and
was appropriate for rehab by postoperative day four [**2112-6-14**].

The patient will follow up with Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] in two
weeks and during the same visit had a T tube cholangiogram
performed prior to seeing Dr. [**Last Name (STitle) 519**]. The patient will also go
to rehab for further physical therapy rehabilitation and
medical care.






[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] M.D. [**MD Number(1) 521**]

Dictated By:[**Name8 (MD) 522**]
MEDQUIST36

D: [**2112-6-14**] 10:25
T: [**2112-6-14**] 10:37
JOB#: [**Job Number 523**]
Admission Date: [**2112-7-2**] Discharge Date: [**2112-7-11**]


Service: GREEN GENERAL SURGERY

HISTORY OF PRESENT ILLNESS: This 81-year-old elderly lady
underwent an open cholecystectomy and common bile duct
exploration for type I Mirizzi syndrome DISEASE three weeks prior to
admission. On [**2112-7-1**] one day prior to admission
she had a normal T-tube cholangiogram without antibiotic
coverage. She was seen by Dr. [**Last Name (STitle) 519**] in his office and
approximately two hours later removed the T-tube without
incident. After the removal of the tube the patient
developed progressive nausea DISEASE and chills DISEASE and right sided
abdominal pain DISEASE as reported by her daughter. She presented to
the [**Hospital6 256**] Emergency Department
hypotensive DISEASE to 80s systolic and acidotic leading to
intubation and institution of pressor support. Her white
count at the time of admission was 12 with a total bilirubin
of 3.6. AST and ALT were both above 500 with an alkaline
phosphatase of 334. Her amylase and lipase were both in the
normal range.

On examination at the time of admission Mrs. [**Known firstname 524**]
[**Name (STitle) 525**] abdomen was soft with mild right upper quadrant
guarding. CT examination showed no collection and a mildly
dilated common bile duct DISEASE . Ascending cholangitis DISEASE secondary to
seeding at the time of cholangiogram with stricture DISEASE at the
T-tube site with or without a retained stone was the
diagnosis.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE
2. Breast cancer DISEASE
3. High cholesterol
4. Diabetes mellitus DISEASE
5. Hypothyroidism
6. Multinodular goiter DISEASE

PAST SURGICAL HISTORY: Breast lumpectomy in [**2103**] and a
thyroidectomy in [**2106**].

HOME MEDICATIONS:
1. Atenolol
2. Glyburide
3. Synthroid
4. Lipitor
5. ASA

HOSPITAL COURSE: On [**2112-7-3**] Mrs. [**Known lastname 526**] was
admitted to the Surgical Intensive Care Unit for close
management of her respiratory cardiovascular and infectious
status. She was seen by the ERCP service/fellow and she
received an emergency MRCP for ascending cholangitis DISEASE . This
study showed altered papilla anatomy dilated common bile duct DISEASE and question of common hepatic duct stricture DISEASE . There
was no small leak at the site of the cystic duct/T-tube
track. The ERCP resulted in 10 cc of purulent aspirate and a
10 French x 8 cm stent was placed. After this procedure
Mrs. [**Known lastname 526**] continued to be monitored closely in the
Intensive Care Unit where her cardiovascular status was
monitored using a Swan-Ganz catheter.

By hospital day #3 Mrs. [**Known lastname 526**] was showing clinical
improvement from her ascending cholangitis DISEASE . On this day she
started to wean off the ventilator and her white count
declined to 5.7. The rest of Mrs.[**Known lastname 527**] Surgical
Intensive Care Unit course was characterized by progressive
weaning from the ventilators and from dobutamine and other
medications used to support her cardiovascular status.
Intravenous antibiotics consisting of Flagyl ceftriaxone and
ampicillin were continued. The patient was extubated on [**7-7**] and on [**2112-7-9**] she was transferred to the
patient floor out of the Intensive Care Unit and placed on
Levaquin. Her status continued to stabilize and improve on
the floor and her condition at the time of discharge was very
good.

DISCHARGE STATUS: Very good

DISCHARGE DIAGNOSIS: Ascending cholangitis DISEASE

Per consultation with the physical therapy service discharge
of the patient to a rehabilitation center was suggested as
the patient lived alone and would not be able to at the time
of discharge successfully complete all of her necessary
activities of daily life.

FOLLOW UP PLANS: Dr. [**Last Name (STitle) 519**] and this should be done in two
weeks after discharge.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] M.D. [**MD Number(1) 521**]

Dictated By:[**Last Name (NamePattern1) 528**]
MEDQUIST36

D: [**2112-7-11**] 10:36
T: [**2112-7-11**] 10:55
JOB#: [**Job Number 529**]
Admission Date: [**2119-4-6**] Discharge Date: [**2119-4-15**] Service: MEDICINE

Allergies DISEASE :
Bactrim Ds / Zyprexa / Lisinopril

Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Altered Mental Status

Major Surgical or Invasive Procedure:
CT head
MRI/MRA
LP
Larynoscopy


History of Present Illness:
HPI: The patient is an 88 year old female resident at [**First Name5 (NamePattern1) 553**]
[**Last Name (NamePattern1) 554**] [**Hospital3 **] with medical history pertinent for
Parkinson's disease Diabetes DISEASE and recent cornea transplant who
now presents with altered mental status.
Per last progress note from patient's PCP [**Name10 (NameIs) **] patient has been
in her usual state of health with exception of management of a
cervical vertebral fracture DISEASE secondary to fall as well as plans
for a repat penetrating keratoplasty (corneal transplant) s/p
failed prior. The patient was at that time apparently at her
baseline and cleared for surgery. The patient underwent
penetrating keratoplasty on [**2119-3-30**] for indication of failed
graft without complication. The patient was seen by her
ophthalmologist on [**2119-4-4**] with impression that there was
moderate lid edema DISEASE present suggestive of hypersensitivity DISEASE but no
discharge to suggest infection DISEASE . Polysporin was discontinued
(with concern for hypersensitivty per discussion with daughter)
and other meds (Pred 1% TID OS Timolol 0.5% [**Hospital1 **] OU Xalatan QHS
OS Tobradex
[**Doctor Last Name **] OS QHS) continued.
The patient now presents form her [**Hospital3 **] with concern
for altered mental status. Only limited information is available
from available staff at [**Hospital3 400**] with report only that
patient was noted tonight to be acutely confused and Admission Date: [**2141-7-4**] Discharge Date: [**2141-7-10**]


Service: GU


HISTORY OF PRESENT ILLNESS: The patient was admitted on [**2141-7-4**] for a left nephrectomy and periaortic lymph node
dissection and cystoscopy secondary to diagnosis of
transitional carcinoma DISEASE and a left renal mass DISEASE . She was first
seen by Dr. [**Last Name (STitle) **] on [**2141-5-12**] for an evaluation of an
episode of gross hematuria DISEASE that was associated with an
enhancing soft tissue mass in the upper pole of the
infundibulum of the left kidney. This was diagnosed by CT on
[**2141-5-9**]. Now was confirmed by MRI and measured to be
3.3 cm. The patient was then scheduled for a left nephrectomy
and staging studies revealed that the right kidney was OK.
She has no history of UTIs colon cancer smoking DISEASE or dysuria DISEASE .
However there is a positive family history for renal cell
cancer DISEASE in her brother who is currently affected.

ALLERGIES: She reports no known drug allergies DISEASE .

MEDICATIONS: Outpatient medications include Lipitor
Norvasc vitamins and aspirin.

PAST MEDICAL HISTORY: Significant for questionable TIA DISEASE which
gave her temporary memory loss DISEASE . Her past medical history is
negative for a MI angina diabetes colitis COPD DISEASE or any
thyroid disease DISEASE .

PAST SURGICAL HISTORY: Repair of a tendon in her right hand
in the remote past.

SOCIAL HISTORY: No tobacco and no drug use but alcohol use
about 4 times a week.

FAMILY HISTORY: Significant for a brother with renal cell
carcinoma DISEASE .

PHYSICAL EXAMINATION: Vital signs: Afebrile vital signs
stable. General: She appears well and sitting comfortably.
HEENT: No masses. Chest: Clear to auscultation bilaterally.
CV: Normal sinus rhythm. Abdomen soft nontender
nondistended.

HOSPITAL COURSE: She was admitted to the SICU on [**2141-7-4**] after her left nephrectomy periaortic lymph node
dissection and cystoscopy. She did well postoperatively
underwent no events in the SICU and was transferred to the
regular floor the following day on [**2141-7-5**]. She did well
on the floor. Her pain DISEASE was well controlled and she was also
given Ancef for 3 doses. Chest x-ray in the SICU showed a 5
mm pneumothorax DISEASE but the chest tube was pulled. The repeat
chest x-ray performed upon arrival to the floor was negative
for a pneumothorax DISEASE . On [**2141-7-6**] postoperative day 2 the
patient continued to improve. She began to ambulate. Her NG
tube was discontinued. She was taken off telemetry. Yet she
passed no gas there was no flatus. Postoperative day 3 she
continued to improve and she continued to ambulate and still
awaiting return of bowel function. Postoperative day 4 her
abdomen was distended slightly tympanitic. She was returned
to NPO encouraged to ambulate given PCA for her pain DISEASE
control and the results of her abdominal film were pending.
Her abdominal film came back negative. On [**7-9**]
postoperative day 5 she continued to do well and her diet
was advanced as tolerated after she passed gas and ambulation
was encouraged. Postoperative day 6 [**2141-7-10**] the
patient did very well in her whole hospital course was doing
well in the morning and was discharged that evening. She was
given instructions to follow-up with Dr. [**Last Name (STitle) **] as well as
appropriate pain DISEASE medication and Colace.

INPATIENT MEDICATIONS: Inpatient medications include Milk of
Magnesia 30 ml p.o. q.8 hours docusate sodium 100 mg p.o.
b.i.d. morphine sulfate 1.5 mg via PCA potassium chloride
20 mEq and 250 of saline sliding scale insulin amlodipine
2.5 mg p.o. daily famotidine 20 mg p.o. q.24 hours
pantoprazole 40 mg p.o. q.24 hours a liter of normal saline
at 80 ml/hour acetaminophen 325 to 650 mg p.o. q.4-6 hours
p.r.n. fever DISEASE or pain DISEASE atorvastatin 10 mg p.o. daily.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] [**MD Number(1) 559**]

Dictated By:[**Name8 (MD) 560**]
MEDQUIST36
D: [**2141-8-17**] 12:37:49
T: [**2141-8-17**] 14:44:38
Job#: [**Job Number 561**]
Admission Date: [**2102-6-12**] Discharge Date: [**2102-6-16**]

Date of Birth: [**2044-7-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Bactrim / Hismanal / IodineAdmission Date: [**2118-7-10**] Discharge Date: [**2118-7-11**]

Date of Birth: [**2034-1-26**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Respiratory Distress

Major Surgical or Invasive Procedure:
BiPAP


History of Present Illness:
84M PMhx metastatic papillary thyroid CA (s/p resection
radioactive iodine) c/b lung mets DISEASE found to have large cavitary
mass in RLL recent admission with malignant effusion DISEASE Admission Date: [**2101-8-15**] Discharge Date: [**2101-8-29**]


Service: SURGERY

Allergies DISEASE :
Demerol / Shellfish Derived / Aspirin

Attending:[**First Name3 (LF) 598**]
Chief Complaint:
nausea vomiting abdominal distention DISEASE

Major Surgical or Invasive Procedure:
[**2101-8-16**]
Exploratory laparotomy


History of Present Illness:
Pt is [**Age over 90 **] y/o F with h/o COPD DISEASE who presents with 3 day h/o
nausea/vomiting and abdominal distension DISEASE . Pt states that she is
having emesis DISEASE of whatever she ingests and has not had a bowel
movement in the past 3 days. Pt states that she is not having
much abdominal pain DISEASE . No fevers DISEASE or chills DISEASE .


Past Medical History:
PMH:
1. Rheumatoid arthritis DISEASE .
2. Osteoporosis DISEASE
3. Macular degeneration.
4. Hyperparathyroidism DISEASE .
5. Hypothyroidism DISEASE .
6. Mitral regurgitation DISEASE .
7. COPD DISEASE .
8. Kyphoscoliosis.
9. Chronic lower extremity edema.
PSH DISEASE : none


Social History:
lives with husband no etoh or tobacco


Family History:
non contributory

Physical Exam:
Temp 98.6 P 94 BP 128/61 R 24 SaO2 96% 2L
Gen: no acute distress
Heent: no scleral icterus
Neck: supple
Lungs: clear
Heart: regular rate and rhythm
Abd: soft distended nontender no guarding nonrigidAdmission Date: [**2101-11-1**] Discharge Date: [**2101-11-10**]


Service: MEDICINE

Allergies DISEASE :
Demerol / Shellfish Derived / Aspirin

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
hypercarbic respiratory failure DISEASE

Major Surgical or Invasive Procedure:
Intubation [**2101-11-1**]
A line insertion [**2101-11-2**]
PICC line [**2101-11-2**]

History of Present Illness:
[**Age over 90 **]F w/hx of COPD DISEASE on 2L at baseline for last day has had increase
O2 requirement. Per husband/rehab has increased O2 requirement
over the last day. Coughing DISEASE decreased from COPD DISEASE baseline. Yest
was hypoxic and NC uptitrated to 5L. This AM requiring NRB (sats
and circumstances unclear). [**Name2 (NI) **] has been afebrile but has
had increasing LE edema DISEASE .

Per husbands report had not been on home O2 for COPD DISEASE until
placed in rehab in [**Month (only) 205**]. Had been living at home and very
functional until recent admission in [**Month (only) 205**] for N/V/Abd DISEASE
distension. Had a laparotomy and appendix taken and out R
femoral hernia DISEASE repaired. D/ced to rehab and has been there
since. Husband reports that roughly a week ago she had a
worsening cough DISEASE and he thought she had developed bronchitis DISEASE .
From the rehab charts it appears she was put on a prednisone
taper and azithromycin. He reports she had been improving with
these treatments until the last 2 days although his history of
her worsening is very unclear. [**Name2 (NI) **] ED signout from talking to
the nursing home she was more hypoxic yesterday requiring 5L NC
and being placed on a NRB this AM. He reports she was
complaining of no other symptoms but is unclear if there was any
change in her mental status.

He reports that at home baseline before rehab she was able to
talk roughly 50yds before being limited by shortness of breath DISEASE .
She did all the chores cooking and cleaning at the house per
his report and they went out together 3x/week. Since her
admission to the hospital and discharge to rehab he reports she
had not done as well but again his history is somewhat unclear.

ED Course presented with Temp 98.4 HR 96 BP 118/54 RR 44
Sats 100% on NRB DISEASE . Altered here A&O x 1 husband (also in 90s)
says she is fine at rehab baseline. Rales bilateral bases with
JVD at mandible. CXR showed bilateral pleural effusions DISEASE with
infiltrated on RLQ and concern for aspiration. WBC elevated to
17.3 (89% PMNs without bands Bcx drawn and started on
vanco/zosyn. EKG: NSR at 94 NA/NI No ST elevations. Given
combivent trial with 125mg IV methlyprednisone. Initial Chem 7
with HCO3 of 42 BNP of 1700. Initial VBG on NRB showed 7.23 /
112 / 55 / 49. Trialed on BiPAP with ABG showing 7.18 / 138 /
209 / 54. Pt wasn't tolerating BiPAP and kept taking off. Resp
rate high but other VSS. ED called PCP and daughter as pt had
DNR order but no DNI order and husband wanting everything done.
Daughter and PCP decided to intubate and see how things go with
thought that would withdraw care if dosen't recover. Easy
intubation. Intubated with succinylcholine and propofol. After
intubation and propofol BPs dropped to 80s/60s given 1L NS and
switched to Midazolam and Fentanyl. Did not require pressors and
BPs came up to 110-120s. No CVL placed (2 PIV). Yellowish fluid
from lungs after intubation (unclear when was aspirating - with
intubation vs yest).

VS on ICU arrival now: Afebrile BP 106/51 HR 81 RR 20 98% on
100% FiO2 on Vent. Pt unable to respond to questioning and so no
ROS could be obtained.


Past Medical History:
PMH:
1. Rheumatoid arthritis DISEASE .
2. Osteoporosis DISEASE
3. Macular degeneration.
4. Hyperparathyroidism DISEASE .
5. Hypothyroidism DISEASE .
6. Mitral regurgitation DISEASE .
7. COPD DISEASE .
8. Kyphoscoliosis.
9. Chronic lower extremity edema.
PSH DISEASE : none


Social History:
At rehab since hernia DISEASE and appendectomy surgery [**8-15**]. no etoh or
tobacco


Family History:
No family history of pulmonary disease DISEASE or clotting disorders DISEASE .

Physical Exam:
Admission physical exam:
Vitals: T: 98.5 BP: 141/56 P: 88 R: 18 O2: 100% on 100% FiO2
General: Opens eyse to voice intubated
HEENT: Sclera anicteric dry MM DISEASE
Neck: supple no LAD no JVP elevation
Lungs: Diffuse ronchi bilaterally with decreased air movement
CV: RR with occasional ectopic beats normal S1 Admission Date: [**2191-5-9**] Discharge Date: [**2191-5-14**]

Date of Birth: [**2108-6-9**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
82 year old male with HTN DISEASE chronic CHF DISEASE and COPD DISEASE BIBA after
developing SOB. Pt has noted increasing SOB on exertion over the
past week. Has also noted occasional episodes of diarrhea DISEASE and
rare short bouts of chest pain DISEASE . Increasing DOE on exertion
yesterday. Today walked to his car and was so short of breath he
leaned on the [**Doctor Last Name 534**] to attract attention for help. A neighbor
came and found him and called an ambulance.
.
Of note pt was also admitted [**2190-1-30**] for SOB c/w CHF DISEASE
exacerbation responded to lasix.
.
When EMS arrived they noted his BP to be 200/100.
.
In the ED inital vitals were HR: 100 BP: 134/109 Resp: 34
O(2)Sat: 92 (CPAP)low. Labs showed CBC 8.2Admission Date: [**2143-4-25**] Discharge Date: [**2143-4-30**]

Date of Birth: [**2076-8-18**] Sex: M

Service: Cardiac Surgery

CHIEF COMPLAINT: Chest pain DISEASE 3-vessel disease on
catheterization.

HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
male transferred from [**Hospital6 33**] to the [**Hospital1 346**] status post catheterization
revealing 3-vessel cardiac disease DISEASE .

The patient presented to [**Hospital6 33**] with gradually
increasing chest pain DISEASE over the past three to four months to
the point that he had chest pain DISEASE with minimal exertion.

PAST MEDICAL HISTORY:
1. Known coronary artery disease DISEASE status post
catheterization 10 years ago at [**Hospital1 **].
2. Heavy smoker.
3. Hypertension DISEASE .
4. Gastroesophageal reflux disease/peptic ulcer disease DISEASE .
5. Wegener granulomatosis DISEASE with complete resolution.
6. Glaucoma.

PAST SURGICAL HISTORY: Perforated ulcer DISEASE .

MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d.
Prilosec 20 mg p.o. q.d. Cosopt eyedrops Alphagan eyedrops
Travatan eyedrops lansoprazole 50 mg p.o. q.d.

ALLERGIES: No known drug allergies DISEASE .

HOSPITAL COURSE: The patient underwent an elective coronary
artery bypass graft times three on [**2143-4-26**] with grafts
being a left internal mammary artery to left anterior
descending artery saphenous vein graft to ramus and
saphenous vein graft to posterior descending artery. He was
extubated on the day of surgery. On postoperative day one
his nasogastric tubes were discontinued.

He was transferred to the regular floor on postoperative day
one. He subsequently had a smooth postoperative course. His
pacing wires were discontinued on postoperative day three.

By postoperative day he was ambulating well. He was
comfortable on p.o. pain DISEASE medication and he was ready for
discharge home.

MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. q.d. (for one week).
2. KCL 20 mEq p.o. q.d. (for one week).
3. Colace 100 mg p.o. b.i.d.
4. Zantac 150 mg p.o. b.i.d.
5. Enteric-coated aspirin 325 mg p.o. q.d.
6. Alphagan eyedrops.
7. Lopressor 50 mg p.o. b.i.d.
8. Nicoderm patch 22 mg q.d.
9. Percocet one to two tablets p.o. q.4-6h. p.r.n.

DI[**Last Name (STitle) 408**]E FOLLOWUP: Follow up with primary care physician
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2208**] in two weeks and with Dr. [**Last Name (Prefixes) **] in
four weeks.

CONDITION AT DISCHARGE: Condition on discharge was stable.

DISCHARGE STATUS: Discharged to home.




[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]

Dictated By:[**Last Name (NamePattern1) 2209**]

MEDQUIST36

D: [**2143-4-30**] 15:09
T: [**2143-4-30**] 15:31
JOB#: [**Job Number 2211**]
Admission Date: [**2158-2-14**] Discharge Date: [**2158-3-6**]


Service: NEUROLOGY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
transferred for seizures DISEASE

Major Surgical or Invasive Procedure:
intubation



History of Present Illness:
86y M with PMH significant for HTN DISEASE CAD s/p CABG afib (now on
warfarin) stroke DISEASE 2y ago and a seizure disorder DISEASE on Keppra
(previously seen in clinic by Dr. [**Last Name (STitle) 619**]. atrial
fibrillation DISEASE on Coumadin. who presents with left ear pain DISEASE . He
presented to the OSH ED ([**Hospital1 **]-[**Location (un) 620**]) 1wk PTA with CC: ear pain DISEASE .
He was sent home with Dx of cerumen in external canal. His ear
pain DISEASE continued and this past Friday his PCP prescribed [**Name9 (PRE) 621**] gtt
for presumed otitis DISEASE externa. Per his son he developed
progressive confusion DISEASE and imbalance. He became unable to walk
and became more somnolent.

He returned to the ED at [**Hospital1 **]-[**Location (un) 620**] in the evening of [**2158-2-13**]
(1d
prior to transfer here) where his VS were notable for fever DISEASE to
102.2F (after arriving afebrile) and tachycardia DISEASE (normalized
with
1.5 L IVF) and exam was notable for somnolence DISEASE . His WBC was
elevated at 14.9. INR was 3.3. Dig 0.84. Troponin negative. UA
Admission Date: [**2189-8-5**] Discharge Date: [**2189-8-11**]

Date of Birth: [**2142-2-22**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
nausea DISEASE and vomiting DISEASE


Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms. [**Known lastname 634**] is a 47 year old female with past medical history
of hypothyrodism DISEASE who was doing well until yesterday. She had
three episodes of nonbloody emesis DISEASE followed by fourth episode at
8 am with streak of blood. She did well throughout the day
until 6 pm when she had one cup full of hematemesis DISEASE leading her
to present to the ED.

In the ED initial vitals were HR 66 and BP 121/72. She had [**1-5**]
cup of hematemesis DISEASE in the ED. Nasogastric lavage returned Admission Date: [**2125-2-13**] Discharge Date: [**2125-2-22**]

Date of Birth: [**2062-5-2**] Sex: M

Service:

DISCHARGE DIAGNOSIS: Right temporal and putaminal hemorrhage DISEASE
secondary to amyloid angiopathy.

CHIEF COMPLAINT: Left-sided weakness for 2Admission Date: [**2132-4-10**] Discharge Date: [**2132-4-12**]

Date of Birth: [**2062-5-2**] Sex: M

Service: [**Year (4 digits) 662**]

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 663**]
Chief Complaint:
GI Bleed

Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy


History of Present Illness:
69 yo man with dementia DISEASE (AAO x 1 and communicative at baseline)
hx stroke DISEASE with dense L hemiplegia DISEASE hx of GIB DISEASE [**2121**] secondary to
duodenal ulcer DISEASE who was BIBA for unresponsiveness. Per his
wife his caretaker moved him to his wheelchair. Around 9am he
lost consciousness and was noted to be diaphoretic and more
rigid. He was moved to his bed where he remained unresponsive
with coffee ground emesis DISEASE in his mouth. EMS was called and pt
regained consciousness in the ambulance.

In the ED initial VS were: T 97.1 P 84 BP 126/90 RR 18
O2sat 95 RA DISEASE . NG lavage was grossly positive with bright red
blood clots and coffee grounds. Pt was guaiac negative. Hct
44 Plt 214 INR 1. Two 18 gauge PIVs placed for access and
patient typed & crossed for 2 unitsAdmission Date: [**2173-6-30**] Discharge Date: [**2173-7-15**]

Date of Birth: [**2095-6-20**] Sex: M

Service: SURGERY

Allergies DISEASE :
Cozaar

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
nausea vomiting DISEASE


Major Surgical or Invasive Procedure:
[**2173-6-30**] ex lap reduction of volvulus enterotomy repair
[**2173-7-13**] AVG thrombectomy


History of Present Illness:
78 M presents with 24 hours of nausea DISEASE multiple bouts of
emesis DISEASE and abdominal pain DISEASE . Has thrown up non-stop overnight.
Reports not passing gas today but has had loose stool. Denies
fevers chills DISEASE or any urinary sypmtoms.


Past Medical History:
- DM
- HTN DISEASE
- Dyslipidemia DISEASE
- Laser surgery to both eyes
- Bilateral cataracts DISEASE
- ESRD DISEASE on dialysis MWF
- Atrial flutter/atrial fibrillation DISEASE s/p ablation. He is
reportedly not on anticoagulation because of renal insufficiency DISEASE
and concern for high risk of bleeding DISEASE .
- s/p pacemaker placement with history of tachy-brady DISEASE syndrome
- Prostate cancer DISEASE diagnosed 12 years ago s/p orchietctomy and
hormone therapy
- Renal cell cancer s/p right nephrectomy
- Secondary hyperparathyroidism
- Small bilateral pleural effusions DISEASE noted on [**2172-1-17**]
admission no longer noted on recent chest x-ray from [**2172-9-24**]
- Percutaneous thrombectomy of his left forearm AV graft
fistulogram
arteriogram and a balloon angioplasty of multiple venous
outflow
stenoses and angioplasty of the arteriovenous graft anastomosis
in [**2172-6-16**]
-s/p surgical removal of upper GI obstruction per patient


Social History:
Retired foundry worker who lives at home in [**Location (un) 669**] with his
wife. Stopped smoking cigarettes over 20 years ago smoked
intermittently for years before that but has difficulty
quantifying use. Has not had alcohol in over 20 years drinking
only socially prior to that time. Denies a history of drug use.



Family History:
Family History:
States that his siblings are healthy but unsure on health of
other family members


Physical Exam:
97.6 99/48 78 18 100% RA DISEASE

Awake alert oriented x 3 NAD
NG tube in place
PERRL anicteric
RRR
CTAB
Abdomen soft distended tender along midline incision and left
side of the abdomen hypoactive bowel sounds DISEASE Admission Date: [**2173-7-24**] Discharge Date: [**2173-7-28**]

Date of Birth: [**2095-6-20**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Cozaar

Attending:[**First Name3 (LF) 678**]
Chief Complaint:
bright red blood per rectum

Major Surgical or Invasive Procedure:
none


History of Present Illness:
78 year old male with a past medical history significant for DM
HTN atrial fibrillation DISEASE on coumadin hx tachy-brady s/p
pacemaker ESRD DISEASE on HD DISEASE s/p recent ex-lap *2 for small bowel obstruction DISEASE night prior to admission BRBPR with INR 2.7 HCT 28
at rehab.

In the ED T 98.3 HR 64 BP 96/44 RR 16 O2 sat: 100%. Two large
bloody bowel movements DISEASE 1 hour apart for which patient recieved 2
units packed rbc 2 unit FFP vit K 10 mg IV Factor 9. Patient
is negative NG lavage then NG tube was removed. Patient seen by
surgery who felt likely due to diverticular bleed DISEASE . GI is aware
and will evaluate once in the unit. Patient came in with triple
lumen and an 18 gauge was placed. EKG with ST depressions
lateral leads with elevated troponin. Cardiology reviewed EKG
and did not feel acute cardiac issue. Most recent vitals T 97.2
P 60 BP 150/42 R 14 O2 sat 100% on 2LNC.

Upon arrival to the intensive care unit. Patient reports no
further episodes of BRBPR. Patient endorses tender abdomen with
any touch but painless at rest. Patient is very hungry but
reports he has been eating only small amounts at rehab. Patient
reports cough DISEASE productive of brown/red sputum since NG tube
placement for SBO. Patient was lightheaded this AM but that
resolved with the transfusions.

Review of systems:
(Admission Date: [**2173-8-27**] Discharge Date: [**2173-9-10**]

Date of Birth: [**2095-6-20**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Cozaar

Attending:[**First Name3 (LF) 678**]
Chief Complaint:
78 yo male with ESRD DISEASE came in with abdominal pain DISEASE

Major Surgical or Invasive Procedure:
Ultrasound-guided percutaneous cholecystostomy with
no immediate complications. 8-French catheter was left in situ
in satisfactory position.

PICC line placement

Percutaneous cholecystostomy tube removal by patient


History of Present Illness:
78 year old male who is status post exploratory laparotomy
lysis of adhesions DISEASE and reduction of small bowel volvulus DISEASE in
[**6-/2173**] by Dr [**First Name (STitle) **] was admitted with
diffuse abdominal pain DISEASE for one month. He had a CT scan and RUQ
US that showed cholilithiasis thickened wall and [**Doctor Last Name 515**] sign.


Past Medical History:
- DM
- HTN DISEASE
- Dyslipidemia DISEASE
- Laser surgery to both eyes
- Bilateral cataracts DISEASE
- ESRD DISEASE on dialysis MWF
- Atrial flutter/atrial fibrillation DISEASE s/p ablation. He is
reportedly not on anticoagulation because of renal insufficiency DISEASE
and concern for high risk of bleeding DISEASE .
- s/p pacemaker placement with history of tachy-brady DISEASE syndrome
- Prostate cancer DISEASE diagnosed 12 years ago s/p orchietctomy and
hormone therapy
- Renal cell cancer s/p right nephrectomy
- Secondary hyperparathyroidism
- Small bilateral pleural effusions DISEASE noted on [**2172-1-17**]
admission no longer noted on recent chest x-ray from [**2172-9-24**]
- Percutaneous thrombectomy of his left forearm AV graft
fistulogram
arteriogram and a balloon angioplasty of multiple venous
outflow
stenoses and angioplasty of the arteriovenous graft anastomosis
in [**2172-6-16**]
-s/p surgical removal of upper GI obstruction per patient


Social History:
Retired foundry worker who lives at home in [**Location (un) 669**] with his
wife. Stopped smoking cigarettes over 20 years ago smoked
intermittently for years before that but has difficulty
quantifying use. Has not had alcohol in over 20 years drinking
only socially prior to that time. Denies a history of drug use.



Family History:
Family History:
States that his siblings are healthy but unsure on health of
other family members


Physical Exam:
Exam at admission:

Vital Signs: T 97.4 HR 86 BP 104/42 RR 18 O2 Sat 100
General: No acute distress
Cardiovascular: Regular rate and rhythm
Respiratory: Clear to auscultation bilaterally
Abdomen: midline incision well healed. No erythema DISEASE . Soft
diffusely tender nondistended no tap tenderness
.


Pertinent Results:
Labs on Admission:

[**2173-8-27**] 08:05PM WBC-9.2 RBC-3.63* HGB-10.3* HCT-33.4* MCV-92
MCH-28.2 MCHC-30.8* RDW-15.9*
[**2173-8-27**] 08:05PM ALT(SGPT)-62* AST(SGOT)-43* ALK PHOS-87 TOT
BILI-0.6
[**2173-8-27**] 08:05PM PT-14.8* PTT-37.6* INR(PT)-1.3*
[**2173-8-27**] 08:22PM LACTATE-2.0 KAdmission Date: [**2160-4-10**] Discharge Date: [**2160-4-17**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Rectal bleeding DISEASE

Major Surgical or Invasive Procedure:
Colonoscopy
Esophagogastroduodenoscopy


History of Present Illness:
87 yo F with h/o CAD A fib on coumadin HTN hyperchol
hypothyroidism DISEASE p/w melena DISEASE . Pt notes that for the past 2.5 weeks
she has been Admission Date: [**2119-6-7**] Discharge Date: [**2119-7-18**]

Date of Birth: [**2063-7-15**] Sex: F

Service: SURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Unresponsive


Major Surgical or Invasive Procedure:
evacuation of abdominal wall hematoma DISEASE and paracentesis
re-exploration of abdominal wall hematoma DISEASE with surgicel packing


History of Present Illness:
55yoF with alcoholic cirrhosis s/p TIPS [**1-/2118**] DISEASE found down by her
husband.

The patient has a history of depression DISEASE which her husband [**Name (NI) **]
reports has been exacerbated lately by several stressful
situations including her chronic back pain DISEASE finances etc. She
was last seen to be interactive and appropriate at 06:00am this
morning by her husband. [**Name (NI) **] son saw her at 11am but thought
the patient was asleep and did not attempt to wake her. She was
subsequently found down on the floor by her husband at 3pm 9
hours after last being seen who describes her as being in a
fetal position with her eyes rolled to the back of her head and
her mouth wide open. Her husband began to lift the patient off
the floor and she bit him on the shoulder and did not appear to
recognize him. She was take to [**Hospital6 33**] where she
was was found to be responsive to verbal stimuli but unable to
interact appropriately. She was intubated. Coffee grounds
returned from her OGT and she was hypotensive DISEASE in the 80's/40's.
FS was 22 and received glucose T was 94.6 and she was placed
on a bear hugger. pH was 6.8 lacate 25 creatine 3.2 bicarb
4. She was received 2 amps bicarb 1 amp D50 and blood
cultures were drawn from her central line. She was started on
bicarb drip levophed gtt for SBP 80's. She not making urine
after 6L IVF. She was transferred to [**Hospital1 18**] for further
management. R IJ was placed at the OSH and 2 peripheral IVs.
.
Per the husband's report the patient does have a history of
surreptitious alcohol ingestion on occasion but he has not
noticed or detected any alcohol use recently. He denies the
likelihood of illicit drug use or prescription drug overdose DISEASE
stating the only medication she has access to is Tramadol which
she had not been taking. He denies recent vocalizations by the
patient regarding suicidal ideation DISEASE .
.
In the [**Hospital1 18**] ED initial VS: 123 113/29 27 100%
The patient was noted to have 150cc dark coffee ground output
from her OGT but stool was guiac negative. Hepatology was
consulted and the patient was started on an Octreotide gtt and
Pantoprazole gtt and aggressive flushing DISEASE of the OGT was
recommended. She was ordered to be transfused 1 unit PRBC. She
was empirically treated with Vanc/Levo/Flagyl and CT torso was
obtained which showed no evidence of infection DISEASE or acute bleed DISEASE .
She received 8L IVF in the ED and was increased on Levophed
0.4mcg/kg/hr. Renal was consulted as the patient had a poor UOP
and was acidotic and CVVH vs hemodialysis was discussed. The
patient was given Calcium gluconate 2gm Bicarb gtt Admission Date: [**2108-5-9**] Discharge Date: [**2108-5-17**]

Date of Birth: [**2023-10-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Fever cough DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname 711**] is an 84 M with h/o MI CABG CHF DISEASE presents with 4
days of worsening mildly productive cough DISEASE . On the night before
admission his cough DISEASE worsened and he felt warm with a fever DISEASE to
101. He tried his wife's albuterol which did not help. He denies
SOB sore throat congestion chest pain lightheadedness DISEASE
headache DISEASE dysuria/frequency abdominal pain DISEASE
diarrhea/constipation. Over the past month he has reduced his
salt intake and lost 25 lbs after being in congestive heart
failure. He no longer has any lower extremity edema. He recently
had shingles DISEASE over his right eye.
.
In the ED initial VS were: 100 94 117/46 18 95/ 2LNC. Exam
bilateral rales RAdmission Date: [**2199-2-8**] Discharge Date: [**2199-2-14**]

Date of Birth: [**2161-11-27**] Sex: M

Service: TRAUMA SURGERY

HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 2212**] is a 37-year-old
male who was stabbed by a four inch knife to the left upper
abdomen. In the field his blood pressure was 120/palpable
heart rate 120. A pressure dressing was applied to the
wound. Reportedly the knife penetrated about 1.5 inches.

PAST MEDICAL HISTORY:
1. HIV positive for 21 years.
2. History of intravenous drug abuse DISEASE .
3. Hypertension DISEASE .
4. Congestive heart failure DISEASE .
5. Right above the knee amputation after being hit by a
truck in the past.
6. Tricuspid regurgitation.

ADMISSION MEDICATIONS:
1. Epivir.
2. Ziagen.
3. Bactrim Double Strength.
4. Lasix.
5. Methadone.
6. Lopressor.
7. Prilosec.
8. Risperdal.
9. Aldactone.
10. Folate.
11. Multivitamins.
12. Thiamine.

ALLERGIES: The patient has an allergy DISEASE to penicillin.

PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.3 heart rate 116 blood pressure 140/palpable
respiratory rate 16 pulse oximetry of 100%. General: He
was alert and oriented times three with a GCS DISEASE of 15. HEENT:
Normocephalic atraumatic. Extraocular motions were intact.
The pupils were equal round and reactive to light and
accommodation. The oropharynx was clear. The TMs were
clear. Chest: Clear to auscultation bilaterally with no
subcutaneous air noted. Cardiac: No murmurs rubs or
gallops. Regular rate and rhythm. Abdomen: There was a 1.5
cm left upper quadrant wound otherwise diffusely tender.
Back: No step-off DISEASE . No deformities DISEASE . Nontender.
Extremities: A right above the knee amputation with
prosthesis. Left leg with chronic venostasis changes.
Rectal: Good tone. Contaminated by external blood.
Neurological: No focal deficits DISEASE .

LABORATORY DATA UPON ADMISSION: Chemistries generally normal
with creatinine of 1.2. Blood gas 7.39/49/341/31/4 lactate
2.5 amylase 107 fibrinogen 171. PT 15.8 PTT 36.1 INR
1.7. His white blood count was 5.1 hematocrit 34.4. Urine
toxicology was not performed.

A chest x-ray was within normal limits status post left
subclavian line placement which was in place.

HOSPITAL COURSE: The patient was taken to the Operating Room
for wound exploration directly from the Trauma DISEASE Room. The
patient was taken to the Operating Room as mentioned above
for an exploratory laparotomy extensive lysis of adhesions
and control of rectus and omental bleeding DISEASE . The estimated
blood loss DISEASE was approximately 1000 cc. Please see the
operative note dictated by Dr. [**Last Name (STitle) **] on [**2199-2-8**] for
complete report.

The patient was then transferred to the SICU where his
coagulopathy DISEASE was corrected. He received 4 units of packed
red cells 4 units of FFP and 1 cryoprecipitate.

While on the unit he was extubated on [**2199-2-10**] SICU
day number three and he was noted to have progressive
thrombocytopenia DISEASE . His home p.o. medications were restarted
as well.

On [**2199-2-11**] hospital day number four the patient
was transferred to the floor. His diet was advanced and he
was placed on an aggressive bowel DISEASE regimen to get his bowels
moving postsurgically. The Pain DISEASE Service was also consulted
because of the patient's history of narcotic abuse and his
continued complaints of pain DISEASE . They recommended increasing
his dose of Klonopin and starting MSIR.

On hospital day number five the patient was noted to have a
heparin-induced DISEASE antibody which may be one of the reasons he
was coagulopathic DISEASE on admission although his HIV disease DISEASE and
other drug abuse DISEASE cannot be ruled out as cause. His platelet
count remained relatively stable however as did his
hematocrit.

By hospital day number six the patient was doing somewhat
betterAdmission Date: [**2157-3-21**] Discharge Date: [**2157-3-27**]

Date of Birth: [**2093-2-22**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: 64-year-old woman with history
of right parietal occipital hemorrhage in [**10/2156**] with an
admission to the Neurology service. She presented with
headaches DISEASE and unsteadiness DISEASE the last two weeks. Headaches are
unclear duration. Very forgetful since [**54**]/[**2156**]. She has
been slowing down as per her family. Being forgetful
positive chills DISEASE no fevers DISEASE positive nausea DISEASE no vomiting DISEASE
positive diarrhea DISEASE over last two to three days cough DISEASE positive
last three days.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE .
2. Anxiety.
3. Hepatitis C.
4. Right parietal-occipital hemorrhage DISEASE in 09/[**2156**].
5. Normal stress test in 11/[**2156**].

MEDICATIONS:
1. Keppra.
2. Metoprolol.
3. Epogen.

ALLERGIES:
1. Penicillin.
2. Codeine.

SOCIAL HISTORY: Lives aloneAdmission Date: [**2157-3-20**] Discharge Date: [**2157-3-30**]

Date of Birth: [**2093-2-22**] Sex: F

Service: NEUROSURGERY

HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
woman with a history of right parietal occipital hemorrhage
in [**2156-10-4**]. She was admitted at that time to the
Neurology Service.

She presented with headaches DISEASE and unsteadiness DISEASE for the last
two weeks. Headaches were of unclear duration as she has
become very forgetful since [**2156-2-4**].

She has been getting lost in the grocery store has had no
fever DISEASE positive nausea DISEASE no vomiting DISEASE positive diarrhea DISEASE for
the last 2-3 days. She has had positive chest pain DISEASE on and
off but none over the last two days prior to admission. No
cough DISEASE over the last two days prior to admission.

PHYSICAL EXAMINATION: Vital signs: Temperature 97.8Admission Date: [**2199-3-18**] Discharge Date: [**2199-3-25**]

Date of Birth: [**2139-8-15**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hypertensive DISEASE urgency

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is a 59 yo F with a history of DM2 DISEASE and HTN DISEASE who presents
with L greater than R flank pain DISEASE associated with nausea DISEASE and
visual blurring DISEASE . Patient has had L sided flank pain DISEASE since the
night prior to admission. This was associated with blurry vision
for the past 1-2 days and headache DISEASE over the last few hours. She
has not had dysuria hematuria vomiting DISEASE or fevers DISEASE . No
abdominal pain DISEASE . No diarrhea DISEASE .

She does have a history of HTN DISEASE and is compliant with her
antihypertensives.

Of note she had much more severe flank pain DISEASE 6 weeks ago. She
was told to drink fluids for potential kidney stone DISEASE . She had
imaging done in [**State 760**] at her home that showed no obvious
stones. Apparently she was referred to a nephrologist at that
time and was told she had some evidence of kidney failure DISEASE . She
was first told she may have kidney failure DISEASE in [**2198-4-22**]. She was
seen by nephrology but does not know any further details. She
has never been on dialysis before. She did not have this flank
pain DISEASE at that time.

Patient brought labs from previous appointments.
[**1-16**] Cr 3.29.
[**2-4**] Cr 3.07 HCT 31.1.

In the emergency department BP was 221/71. She recived 200mg IV
labetalol and was started on a 1mg/min labetalol gtt. BP came
down to 176/92. HR 77. RR21. O2 sat 88%.

On arrival to the MICU patient's flank pain DISEASE is much improved.
No headache nausea vomiting chest pain DISEASE or shortness of
breath.

Past Medical History:
1. Diabetes DISEASE
2. Asthma
3. Depression DISEASE
4. History of pulmonary nodules consistent with calcified
granuloma DISEASE
5. Menorrhagia DISEASE
6. Hypertension DISEASE
7. Hypercholesterolemia DISEASE .
8. Chronic lower back pain DISEASE .
9. CRI most recent Cr values in the low 3's.
10. Thyroid mass - she reports she was told she had a 2 cm
thyroid mass DISEASE and needed to have this biopsied.
11. Osteoporosis DISEASE


Social History:
She lives in NJ currently with a roommate but wants to move
back to MA. Smokes 1 ppd. Denies alcohol or drug use.

Family History:
Uncle and two cousins had kidney disease DISEASE requiring dialysis.

Physical Exam:
Vitals - T: BP: HR: RR: 02 sat:
GENERAL: Pleasant well appearing female sitting on the bed in
NAD
HEENT: Normocephalic atraumatic. No conjunctival pallor DISEASE . No
scleral icterus DISEASE . PERRLA/EOMI. MMM. OP clear.
NECK: Full thyroid bilaterally with a focal small nodule on the
left lobe.
CARDIAC: Regular rhythm normal rate. Normal S1 S2. No murmurs
rubs or [**Last Name (un) 549**].
LUNGS: Patient breathing comfortably. CTAB good air movement
biaterally.
ABDOMEN: Admission Date: [**2200-4-25**] Discharge Date: [**2200-4-28**]

Date of Birth: [**2139-8-15**] Sex: F

Service: [**Year (4 digits) **]

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 824**]
Chief Complaint:
R renal mass

Major Surgical or Invasive Procedure:
Right Laparoscopic Radical Nephrectomy


History of Present Illness:
60yF with CAD and ESRD DISEASE on HD DISEASE with a nearly 4cm left renal mass
concerning for malignancy DISEASE .

Past Medical History:
1. Diabetes type 2 c/b retinopathy neuropathy DISEASE - pt not
currently taking meds due to insurance issue
2. Reactive airway diseaseAdmission Date: [**2200-10-21**] Discharge Date: [**2200-10-27**]

Date of Birth: [**2139-8-15**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Iron Dextran Complex

Attending:[**First Name3 (LF) 832**]
Chief Complaint:
respiratory failure DISEASE

Major Surgical or Invasive Procedure:
Bronchoscopy
Intubation
Hemodialysis after HD line placement

History of Present Illness:
61 year-old female with ESRD DISEASE on HD DISEASE Stage IV NSLC lung cancer DISEASE
(EGFR wild type) DM2 HTN DISEASE who presents with respiratory
distress.

Patient was with cough DISEASE and not feeling well this AM. She went to
dialysis where she was coughing intensely to the point that the
needles came out of her AV graft. She appeared short of breath.
Unclear what EMS course was. Upon presentation to the ED her
eyes were open but she was none verbal. Some history obtained by
cousin in [**Name (NI) **].

Of note her lung cancer DISEASE involves the right upper lobe mass and
adjacent hilar/mediastinal/supraclavicular nodes. Patient met
with Dr. [**Last Name (STitle) **] in [**Month (only) **] who started vinorelbin for
palliative chemotherapy about 2 weeks ago.

In addition patient's admit weight was 62 kg with an estimated
dry weight of 58 kg.

ED Course:
Initial VS at 11:40 on [**10-21**] were T 97.7 HR 100 BP 181/69 RR 32
Sat 84 %. She triggered for respiratory distress DISEASE . Eyes were open
but non-verbal. There was a question about intubation/code
status. ED physician spoke to next of [**Doctor First Name **] (Mr.[**Last Name (Titles) 732**]). He stated
that she would want to be intubated. Intubated with 7.5 ETT with
ricironium 60 mg and etomidate 20 mg. Sedation with versed and
propofol. After intubation VS were 95 125/59 25 99% on vent

CXR revealed RUL opacity. She was given ceftriaxone 1 gm IV x 1
and levofloxacin 750 mg IV x 1 initially followed by addition of
vancomycin 1 gm IV x 1 to cover HCAP DISEASE . EKG showing Sinus Tach
TWI V4-6 Admission Date: [**2143-8-23**] Discharge Date: [**2143-8-27**]

Date of Birth: [**2077-7-13**] Sex: M

Service: CCU


HISTORY OF PRESENT ILLNESS: This is a 66-year-old man with
severe CAD status post CABG in [**2135**] with recent PCI to the
LMCA and SVG to the PDL in [**2143-7-14**]. He presented on
[**2143-8-23**] for an elective intervention brachytherapy of the
SVG to PL and native RCA. The patient reported that he had
been feeling well without chest pain shortness of breath DISEASE or
dyspnea DISEASE on exertion. He was noted to have an ejection
fraction of greater than 60 percent in [**2143-7-14**]. The
patient underwent a cardiac catheterization on the morning of
arrival with PCI to the native RCA and 4 stents and
brachytherapy to the vein graft. The patient tolerated the
procedure well and approximately 6 hours later developed a
chest pain DISEASE noted as 4 out of 10 substernal radiating to his
throat and back without shortness of breath diaphoresis DISEASE
nausea DISEASE or vomiting DISEASE . EKG at that time revealed ST elevation
in II III and aVF. The patient was brought back to the
catheterization laboratory at that time. They found that the
SVG to PL have been thrombosed DISEASE . The artery was opened in the
catheterization laboratory AngioJet had been unsuccessful
and the graft was opened with Nipride with subsequent TIMI 3
flow. The patient had persistently occluded communication
between the native RCA and the vein graft. Postprocedure
after the sheath pull a hematoma DISEASE developed and the patient
had baseline low blood pressure of systolic in the 90s.

PAST MEDICAL HISTORY:
1. Status post MI in [**2129**].
2. PCI to the LAD in [**2130**].
3. PCI to the RCA in [**2132**] complicated by a stent blocking
the femoral artery.
4. Status post iliac repair.
5. Coronary artery bypass graft in [**2135**] including LIMA to the
LAD SVG to the D1 SVG to the RPL DISEASE .
6. PCI to the LMCA in [**2143-7-14**] PCI to the SVG to the PVL.
7. Status post right knee arthroscopy.
8. History of hemorrhoids DISEASE .
9. History of benign polyps.


MEDICATIONS ON PRESENTATION:
1. Aspirin 325 mg a day.
2. Lopressor 12.5 mg b.i.d.
3. Zocor 60 mg a day.
4. Plavix 75 mg a day.


ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: Smokes 10 packs a week for the past 50
years currently trying to quit. Social tobacco with no
illicits.

FAMILY HISTORY: A brother died of MI at age 60. Father had
his first MI in his 50s. The patient is married with several
children. He is currently between jobs. After the
procedure the patient was admitted to the CCU for
monitoring.

PHYSICAL EXAMINATION: His temperature was 98.2 degrees
blood pressure 99/48 respiratory rate 15 100 percent
saturation on room air heart rate 57 to 66. In general he
is a well-appearing elderly male alert and oriented with an
appropriate affect. HEENT revealed no JVD. Supple neck.
Chest revealed clear lungs no rhonchi no crackles.
Cardiovascular normal S1 S2 no murmurs rubs or gallops
no S3 or S4. Abdomen is flat soft nontender nondistended
with normoactive bowel sounds DISEASE . Extremities are warm with
capillary refill less than 3 seconds 2 plus DP and PT and
radial pulses no edema left groin DISEASE with bruit.

LABORATORY DATA: EKG on presentation had a sinus rate of 55
inferior T-wave DISEASE inversions ST elevation in V1 and V2.

IMPRESSION: The patient is a 66-year-old male with a severe
CAD status post brachytherapy SVG to the PDL with
subsequent thrombosis DISEASE status post opening of the artery
during repeat catheterization.

HOSPITAL COURSE: The patient was now hemodynamically stable
with resolution of his EKG changes and ST elevation and he
was admitted to the CCU for monitoring. That evening the
patient complained of back pain DISEASE on his left side which he
attributed to lying on his back. On exam there was no
palpable hematoma DISEASE no bruit auscultated and strong DP pulses
with warm extremities. The CT of the pelvis and abdomen was
negative for retroperitoneal bleed DISEASE . It was determined that
the patient's pain DISEASE was due to back painAdmission Date: [**2188-8-14**] Discharge Date: [**2188-8-23**]


Service: General Surgery - Blue Team

HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old
young lady with a history of hypothyroid DISEASE previous
appendectomy and hysterectomy who presented to the Emergency
Department with a one day history of severe abdominal pain DISEASE .
The patient endorses nausea DISEASE without vomiting sweating DISEASE
dysuria DISEASE chest pain DISEASE and shortness of breath DISEASE . The patient
did not have any prior episodes of this type of pain DISEASE . The
patient has no history of ulcers DISEASE . The patient's last bowel
movement was [**8-14**] it was normal. The patient
tolerated breakfast by mouth today without any complications.

PHYSICAL EXAMINATION: On physical examination the patient
was afebrile 100.0 heartrate 80 blood pressure 148/74
respiratory 24 99% on room air. In general she was alert
and oriented times three. Cardiac examination was irregular.
Chest examination with a fair amount of air entry. Abdominal
examination tenderness guarding DISEASE mainly in the right lower
quadrant. Positive tympani. Extremities were warm no edema DISEASE
or erythema DISEASE . Rectal examination guaiac negative.

LABORATORY DATA: Laboratory data on admission revealed white
count 13.7 hematocrit 42 platelets 397 sodium 139
potassium 4.1 chloride 97 bicarbonate 34 BUN 19
creatinine 1.0 glucose 127. Liver function tests ALT 16
AST 28 alkaline phosphatase 78 total bilirubin 0.5 amylase
43. Urinalysis trace leukocytes small blood trace
ketones red blood cells [**2-13**] and white blood cells [**2-13**].
Chest x-ray showed free air in his diaphragm on the right.
Abdominal x-rays upright film showed free air with air in
the colon. Stool absent all the way down through the colon.

HOSPITAL COURSE: The patient was admitted and placed on
Ampicillin Levofloxacin and Flagyl. Blood cultures were
sent. On hospital day #1 [**2188-8-15**] the patient
underwent partial gastrectomy and gastrojejunostomy with
placement of feeding J-tube for a perforated gastric ulcer DISEASE .
The patient tolerated the procedure well and there were no
complications during the surgery. The patient was placed in
the Intensive Care Unit over night intubated. On [**2188-8-16**] postoperative day #1 the patient was weaned from
ventilator support and extubated without difficulty. The
patient's renal function improved to producing over 30 cc/hr
and soft bowel sounds were appreciated. On postoperative day
#3 the patient was transferred to the floor. On the floor
the patient was started on half-strength tube feeds. Total
parenteral nutrition was continued and by [**8-21**]
postoperative day #6 the patient was tolerating sips. On the
day of [**8-20**] the patient had one episode of atrial
fibrillation DISEASE that was successfully controlled with
intravenous Lopressor. By [**8-22**] the patient was
tolerating liquids without difficulty. Total parenteral
nutrition had been stopped antibiotics had been stopped and
rehabilitation planning had started. Tube feeds were
increased to almost goal. On [**8-23**] the patient was
tolerating full liquids without difficulty and was discharged
to rehabilitation. The patient will be discharged to
[**Hospital **] Rehabilitation in good condition. She is able to
ambulate with assistance tolerate full liquids and has no
further need for antibiotics.

DISCHARGE DIAGNOSIS:
1. Status post partial gastrectomy for perforation DISEASE of gastric
ulcer sepsis DISEASE
2. Status post gastrojejunostomy
3. Status post placement of
feeding J-tube
4. Hypothyroid
5. Status post appendectomy
6. Status post hysterectomy
7. Coronary Artery Disease Hypertension DISEASE
8. Dementia DISEASE
9. Malnutrition DISEASE
10. Esophageal Motility Disorder DISEASE

DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg tablets one to two tablets by mouth
q. 4-6 hours as needed
2. Metoprolol 50 mg tablets [**12-15**] tablet by mouth twice a day
3. Pantoprazole 40 mg tablets one tablet every 24 hours
4. Prednisone 10 mg one tablet by mouth three times a day



[**Name6 (MD) 843**] [**Name8 (MD) 844**] M.D. [**MD Number(1) 845**]

Dictated By:[**Name8 (MD) 846**]
MEDQUIST36

D: [**2188-8-23**] 09:54
T: [**2188-8-23**] 11:26
JOB#: [**Job Number 847**]
Admission Date: [**2164-6-15**] Discharge Date: [**2164-7-13**]

Date of Birth: [**2115-11-19**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /
Tranxene Sd

Attending:[**First Name3 (LF) 848**]
Chief Complaint:
Emesis lethargy DISEASE and decreased PO intake

Major Surgical or Invasive Procedure:
Central Venous Line placement
Small bowel exploratory DISEASE laparotomy
Small-bowel resection with primary anastomosis


History of Present Illness:
A 48-year-old patient who presents episodically for evaluation
of emesis DISEASE . Pt has a complicated PMH including [**Location (un) 849**] Gastaut DISEASE
Syndrome mental retardation DISEASE and seizure disorder DISEASE He was
recently admitted to [**Hospital1 18**] from [**2164-5-4**] to [**2164-5-18**] and
then subsequently to [**Hospital **] Rehabilitation status post ex
lapopen chole J-tube placement and venting decompressed
colotomy for abdominal pain DISEASE . Pt was brought back to [**Hospital1 18**] by
his caregivers because of emesis lethargy DISEASE and decreased PO
intake. It was unclear if the emesis DISEASE was bilious DISEASE or bloody.
Denies DISEASE any change of bowel movements DISEASE . No fevers DISEASE recorded at
living center. No other focal complaints. The patient has been
unable to provide any history. Per caregivers the patient does
not report pain DISEASE although at baseline it is unclear if he
experiences pain DISEASE .


Past Medical History:
[**Location (un) 849**] Gastaut Syndrome [**Location (un) 850**] Dr. [**Last Name (STitle) 851**]
Seizure disorder DISEASE
Mental retardation
Osteoporosis DISEASE
Peripheral neuropathy DISEASE secondary to dilantin
h/o hyponatremia DISEASE secondary to trileptal
GERD
Behavioral d/o
s/p recent ex lap open cholecystectomy J-tube placement and
transverse colon needle decompression

Social History:
Lives in group home. Non-verbal at baseline. Does not smoke or
drink EtOH.
Patient lives in a group home. # [**Telephone/Fax (1) 852**]. Has a legal
guardian Rev [**First Name8 (NamePattern2) **] [**Name (NI) 853**] c # [**Telephone/Fax (1) 854**] w # [**Telephone/Fax (1) 855**].



Family History:
Noncontributory

Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 120/60 temperature 97.7 heart
rate 98.
GENERAL: Gentleman appears chronically ill in a wheelchair
nontoxic.
HEENT: Oropharynx notable for somewhat dry membranes. He is
anicteric.
LUNG: Complicated by poor effort but no crackles are
appreciated.
CARDIAC: Notable for mild tachycardia DISEASE .
ABDOMEN: Soft. J-tube site appears somewhat erythematous.
There is no discharge. There are bowel sounds. No palpable
organomegaly DISEASE .

Neuro Exam very limited since pt is non-verbal at baseline and
unable to cooperate with exam:
MSE: Awake and alertAdmission Date: [**2164-11-23**] Discharge Date: [**2164-12-4**]

Date of Birth: [**2115-11-19**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /
Tranxene Sd

Attending:[**First Name3 (LF) 678**]
Chief Complaint:
[**First Name3 (LF) **]

Major Surgical or Invasive Procedure:
None

History of Present Illness:
49 year-old man with a history of presumed [**Location (un) 849**] Gastaut DISEASE
Syndrome DISEASE and with a recent complicated medical history presents
this morning for a [**Location (un) 862**] in the setting of fever DISEASE . The patient
is nonverbal and the history was obtained through medical record
.
The patient was reportedly well yesterday and was stable when
last checked at 11 pm. He was noted to be Admission Date: [**2166-12-9**] Discharge Date: [**2166-12-21**]

Date of Birth: [**2115-11-19**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /
Tranxene-SD

Attending:[**First Name3 (LF) 678**]
Chief Complaint:
fever DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
51 yo male with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 849**]-Gastaut with MR DISEASE presenting from group
home after one day of fever DISEASE . History provided by worker from
group home. Noted to develop temperature of 99.6 -Admission Date: [**2203-11-3**] Discharge Date: [**2203-11-12**]

Date of Birth: [**2161-11-27**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath chest pain DISEASE

Major Surgical or Invasive Procedure:
Pericardiocentesis
EGD with biopsy


History of Present Illness:
41 y/o M w/ h/o HIV/AIDS (HIV dx 83 AIDS DISEASE 92 last CD4 132 VL
Admission Date: [**2192-5-16**] Discharge Date: [**2192-5-29**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
bloody diarrhea DISEASE x 2 weeks

Major Surgical or Invasive Procedure:
colonoscopy x 2 (Admission Date: [**2192-6-3**] Discharge Date: [**2192-6-10**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Lower gastrointestinal blees DISEASE

Major Surgical or Invasive Procedure:
1. Colonoscopy
2. Tagged RBC GI bleeding DISEASE study


History of Present Illness:
Pt. is an 83y/o F with a PMH of diverticulosis DISEASE recently
discharged on [**2192-5-29**] s/p LGIB DISEASE secondary to bleeding DISEASE
diveriticulus admitted [**6-3**] with BRBPR.
.
During prior hospitalization pt. was admitted with a 2 week
history of BRBPR at home. On [**5-21**] a diverticular bleed DISEASE found on
first colonoscopy epi injected but patient with continued LGIB DISEASE
which was seen in the distal sigmoid on tagged RBC study [**5-24**].
The bleeding DISEASE was not deemed amenable to angio intervention.
Repeat colonoscopy on [**5-25**] not able to identify further source of
bleeding DISEASE . Pt discharged on [**5-29**] with a stable hct.
.
Since that time Pt. was doing well at home until she again had
an episode of BRBPR which she reported to fill the commode. Pt.
also reported L chest pain DISEASE occurring episodically over the past
few days. Pt. brought to ED by her daughter yesterday. In ED
vitals: temp 97 HR 110 BP 161/90 RR 18 O2sat 98% 4LNC. Pt.
soaked her pad on ED bed with BRB. Labs included HCT 37
unremarkable CBC electrolytes CEs and LFTs. CXR unremarkable.
EKG SRAdmission Date: [**2102-4-13**] Discharge Date: [**2102-4-17**]

Date of Birth: [**2026-1-20**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
[**4-13**] MVR (29mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] porcine)


History of Present Illness:
76 yo F walking to dentists office [**3-22**] and had
SOB/CP/diaphoresis. Transferred to [**Hospital1 18**] where cath showed 4Admission Date: [**2102-9-27**] Discharge Date: [**2102-9-30**]

Date of Birth: [**2026-1-20**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI:76yo female retired nun presents from [**Hospital3 934**]
Hospital s/p fall down down [**5-16**] steps. Pt was alert upon ems
arrival and became unresponsive enroute to hospital. Pt. CT scan
revealed bilateral SDH left greater than right. Admission Date: [**2179-5-24**] Discharge Date: [**2179-5-31**]

Date of Birth: [**2116-7-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Percocet / Penicillins / Aspirin / Ibuprofen / Codeine / Reglan
/ Morphine Sulfate / Dilaudid / Demerol / Darvocet-N 100 /
Erythromycin Base / Tetracycline / Oxycodone

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Back pain DISEASE

Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L2-S1


History of Present Illness:
62 year old female with chronic low back pain DISEASE s/p multiple
lumbar surgeries presents for elective anterior/posterior
decompression laminectomy on [**2179-5-25**].

Past Medical History:
h/o depression DISEASE and Admission Date: [**2195-2-5**] Discharge Date: [**2195-5-28**]

Date of Birth: [**2120-5-13**] Sex: F

Service: Cardiothoracic Surgery

CHIEF COMPLAINT: Shortness of breath chest pain DISEASE x 2 weeks.

HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female with increased shortness of breath and chest pain DISEASE with
exertion x 2 weeks. She went to an outside hospital and was
transferred here to [**Hospital1 69**] for
catheterization. The patient had right CA stent placed in
[**2188**]. Cardiac catheterization showed 90% left anterior
descending coronary artery stenosis DISEASE 90% diagonal stenosis
90% circumflex stenosis DISEASE and 80% right coronary artery
stenosis. Ejection fraction was roughly 68%.

PAST MEDICAL HISTORY: 1. Coronary artery disease DISEASE . 2.
Myocardial infarctions DISEASE in the past. 3. Insulin dependent
diabetes mellitus DISEASE . 4. Hypertension DISEASE . 5. Increased
cholesterol. 6. Coronary artery disease DISEASE status post
percutaneous transluminal coronary angioplasty of right
coronary artery in [**2188**]. 7. Skin cancer DISEASE . 8. Sleep apnea DISEASE .
9. History of abdominal hernia DISEASE . 10. Uterine cancer DISEASE status
post radiation. 11. History of vertigo DISEASE . 12. History of
osteoarthritis DISEASE . 13. History of obesity DISEASE .

PAST SURGICAL HISTORY: 1. Status post skin cancer DISEASE excision
of the face. 2. Status post esophageal dilatation. 3.
Status post gastric bypass with hernia DISEASE repair. 4. Status
post total abdominal hysterectomy. 5. Status post right
cataract DISEASE eye surgery.

MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Meclizine 12.5
mg p.o. b.i.d. 3. Lantus 25 units subcutaneous p.m. 4.
Zoloft 75 mg p.o. q.d. 5. Regular insulin 6 units at
breakfast 8 units at lunch 10 units at supper. 6.
Neurontin 300 mg p.o. t.i.d. 7. Norvasc 10 mg p.o. q.d. 8.
Lasix 40 mg p.o. q.d. 9. Lipitor 40 mg p.o. q.d. 10.
Zestril 5 mg p.o. q.d. 11. Scopolamine patch.

ALLERGIES: The patient has no known drug allergies DISEASE .

PHYSICAL EXAMINATION: On initial examination the patient's
heart rate was 76 respiratory rate 12 blood pressure
152/81 initial weight 199 pounds. General: Obese. Skin:
Facial scars. HEENT: Pupils equal round and reactive to
light and accommodation extraocular movements DISEASE intact. Neck:
Positive murmur radiating to right neck. Chest: Bibasilar
crackles. Heart: Regular rate and rhythm Admission Date: [**2195-2-5**] Discharge Date: [**2195-5-28**]

Date of Birth: [**2120-5-13**] Sex: F

Service:

This is an addendum to the discharge summary for the days
[**2-5**] to [**5-28**].

During the month of [**Month (only) 958**] the patient progressed with
physical therapy and treatments of her infections DISEASE with
antibiotics and good nutrition. At the end of [**Month (only) 958**] the
patient had a IJ Perm-A-Cath placed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
The patient tolerated the procedure well and was transported
back to the CSRU in stable condition. During this time the
patient was fed using a post pyloric tube while keeping the
nasogastric tube to suction to allow closure of
enterocutaneous fistula DISEASE . Toward the end of [**Month (only) 958**] the
nasogastric tube was removed. Dr. [**Last Name (STitle) 957**] on the [**4-18**] placed a feeding jejunostomy tube. The patient
tolerated the procedure well and was transported back to the
CSRU in stable condition. Following surgery the patient was
restarted on the tube feeds Nepro 40 cc with 110 grams of
ProMod q.d. The patient continued to progress during her
hospital stay and it was decided that the patient would be
able to be discharged to rehabilitation services for further
physical therapy.

On the [**4-26**] it was decided that the patient will be
able to be transferred to rehabilitation services.

DISCHARGE PHYSICAL EXAMINATION: Temperature max 99.6 99.2.
76 123/36 1000 in 15 cc out in urine. Discharge weight is
86 kilograms which is down 4 kilograms from preoperative
weight of 90 kilograms. She is on CPAP 15 700 12 5 and
50%. The patient had Pseudomonas and Klebsiella in her
sputum and enterococcus in the urine. ID was consulted. The
idea was that Enterobacter would not be covered and that the
Pseudomonas and Klebsiella would be treated with Tobramycin
following verification of infiltrates on a CT scan. The
patient on the [**4-25**] had a scan which showed a left
lower lobe collapse most likely pneumonia DISEASE .

DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft and AVR.
2. Status post PEG tube placement.
3. Status post drainage of abscess DISEASE at the PEG tube site with
an enterocutaneous fistula DISEASE .
4. End stage renal disease DISEASE . Status post dialysis catheter
placement.
5. Status post percutaneous trach placement.
6. Status post J tube placement.
7. Pneumonia DISEASE multiple episodes during hospitalization stay.
8. Right lower leg infection DISEASE with a V.A.C. placement.
9. Chest wound infection DISEASE status post V.A.C. placement.

SECONDARY DIAGNOSES:
1. Insulin dependent diabetes mellitus DISEASE .
2. Hypertension.
3. Increased cholesterol.
4. Skin cancer DISEASE of the face.
5. Sleep apnea DISEASE .
6. Abdominal hernia ventral.
7. Uterine cancer status post radiation.
8. Vertigo.
9. Osteoarthritis.
10. Obesity.

DISCHARGE CONDITION: Stable to rehabilitation services.

DISCHARGE MEDICATIONS:
1. Tobramycin 100 mg intravenous q hemodialysis times
fourteen days. Please check Tobramycin levels with
hemodialysis.
2. Regular insulin sliding scale 121 to 150 3 units 151 to
200 6 units 201 to 250 9 units 251 to 300 12 units 301 to
350 call primary care physician.
3. Lantus 30 units subQ at 8:00 p.m.
4. Metoclopramide 10 mg intravenous q.h.s.
5. Sertraline 100 mg po q.d.
6. Lansoprazole 30 mg po b.i.d.
7. Amiodarone 400 mg po q.d.
8. Tylenol 650 mg po q 6 hours prn.
9. Epogen [**Numeric Identifier 961**] units three times a week.
10. Colace 100 mg po b.i.d.
11. Albuterol one to two puffs po q 4 to 6 hours prn.
12. Miconazole powder 2% topical q.i.d. prn.
13. Ipratropium bromide two puffs inhaler q 4 hours prn.
14. Bisacodyl 10 mg per rectum q.h.s.

DIET: ProMod 110 grams per day and Nepro 2/3 strength at 50
cc an hour continuously.

TREATMENTS: The patient should continue with aggressive
physical therapy and chest physical therapy. The patient
should receive chest physical therapy q four hours. The
patient should have trach trials with 50% FIO2 four hours a
day at 8:00 a.m. 2:00 p.m. and 7:00 p.m. The patient should
have V.A.C. dressing changes to the chest and to the right
lower extremity once a week. At that time the wound should
be evaluated. The patient should also have J tube care.
Until the first follow up with Dr. [**Last Name (STitle) 957**] the dressings for
the J tube should not be changed. The upper wound and lower
wound on the abdomen should have dry dressing changes. The
patient should continue with trach care. The patient will
require laboratories with hemodialysis and Tobramycin levels
with hemodialysis. The patient will follow up with Dr.
[**Last Name (STitle) 70**] in roughly two weeks Dr. [**Last Name (STitle) 962**] in four weeks and
Dr. [**Last Name (STitle) 957**] in two weeks.






[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]

Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36

D: [**2195-5-28**] 08:37
T: [**2195-5-28**] 08:47
JOB#: [**Job Number 963**]
Admission Date: [**2195-6-6**] Discharge Date: [**2195-6-19**]

Date of Birth: [**2120-5-13**] Sex: F

Service: Cardiothoracic Surgery

CONTINUATION:

DISCHARGE MEDICATIONS:
1. Sertraline 150 mg per jejunostomy tube q.d.
2. Lantus insulin 30 units subcutaneous q.p.m.
3. Prevacid 30 mg elixir via jejunostomy tube q.d.
4. Epogen 10000 units IV three times weekly with dialysis
treatments.
5. Heparin 5000 units subcutaneously q. 6 hours.
6. M.V.I. 5 mL via jejunostomy tube q.d.
7. Zinc sulfate 220 mg via jejunostomy tube q.d.
8. Vancomycin 250 mg solution via jejunostomy tube q. 6 hours
for her C. difficile DISEASE .
9. Amiodarone 200 mg via jejunostomy tube q.d.
10. Flagyl 500 mg IV q. 12 hours also for C. difficile DISEASE .
11. Vitamin C 500 mg via jejunostomy tube q.d.
12. Reglan 10 mg IV q. 12 hours.
13. Percocet 5/325 one to two tablets via jejunostomy tube q.
4 hours p.r.n.
14. The patient is on vancomycin 1 gram IV to be dosed
according to a level prior to dialysis treatments. The
patient should be dosed with 1 gram IV for a level less than
15.
15. The patient is receiving tobramycin 70 mg IV with
dialysis dosing and should have her tobramycin levels
checked. She should be redosed with tobramycin when her
level falls below 1.5 that is a trough level.

TREATMENT REQUIRED UPON DISCHARGE:
1. The patient receives wet-to-dry normal saline dressings to
her right lower extremity wounds as well as her abdominal
wound t.i.d.
2. The patient has a V.A.C. dressing in her open sternal
wound which should be changed twice weekly. It was most
recently changed on Thursday [**6-18**].
3. The patient is being tube fed via her jejunostomy tube
full-strength Impact with fiber at 70 mL per hour.
4. The patient's current ventilator settings are CPAP with
pressure support of 5 and PEEP of 5 and FIO2 of 50%. She may
have a Passey-Muir valve p.r.n. to speak. She should have
assistance from the speech therapy department to assist her
with speaking with her tracheostomy.

CONDITION ON DISCHARGE: Fair.

DISCHARGE DIAGNOSES:
1. Sternal wound infection DISEASE status post cardiac surgery
status post limited sternal wound debridements on [**2195-6-9**].
2. End-stage renal disease DISEASE .
3. Respiratory failure DISEASE .
4. Clinical depression DISEASE .
5. Insulin dependent diabetes mellitus DISEASE .





[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]

Dictated By:[**Name8 (MD) 964**]
MEDQUIST36

D: [**2195-6-19**] 12:13
T: [**2195-6-19**] 12:33
JOB#: [**Job Number 965**]
Admission Date: [**2195-6-6**] Discharge Date: [**2195-6-22**]

Date of Birth: [**2120-5-13**] Sex: F

Service: Cardiothoracic

HISTORY OF PRESENT ILLNESS: This is a 75-year-old female
patient who had a very prolonged previous hospitalization at
the [**Hospital1 69**] and was ultimately
discharged on [**2195-5-28**]. During her hospitalization
she underwent coronary artery bypass graft x4 with an aortic
valve replacement. Her postoperative course was complicated
by aspiration wound infection DISEASE of her sternal wound as well
as of her saphenectomy gastrostomy tube placement followed
by necrosis DISEASE of the abdominal wall as well as acute renal failure DISEASE . Please see discharge summary from that
hospitalization for details of her postoperative course after
her cardiac surgery.

The patient was readmitted to the hospital on [**2195-6-6**]
due to fevers DISEASE to 103 at the rehabilitation facility despite
being on intravenous antibiotics. In the Emergency
Department the patient was noted to have a fair amount of
purulent drainage in the open sternal wound. The patient was
admitted to the Surgical Intensive Care Unit at that time.

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post coronary artery bypass
graft as previously noted with an aortic valve replacement
for aortic stenosis DISEASE .
2. End-stage renal disease DISEASE . The patient is hemodialysis
dependent.
3. Hypertension DISEASE .
4. Insulin dependent-diabetes mellitus DISEASE .
5. Sleep apnea DISEASE .
6. Vertigo DISEASE .
7. Osteoarthritis DISEASE .
8. Skin cancer DISEASE in the past.
9. Abdominal hernia DISEASE repair.
10. Uterine cancer DISEASE status post total abdominal hysterectomy.
11. Obesity.

MEDICATIONS ON ADMISSION TO THE HOSPITAL:
1. Tobramycin.
2. Vancomycin.
3. Reglan.
4. Protonix.
5. Amiodarone.
6. Zoloft.
7. Compazine.

ALLERGIES: No known drug allergies DISEASE .

PHYSICAL EXAMINATION ON ADMISSION TO THE HOSPITAL: The
patient was awake and responsive following commands
appropriately. She was on a ventilator via tracheostomy.
HEENT was unremarkable. Her lungs were clear to auscultation
bilaterally. Patient was tachycardic with a regular rate
and rhythm. Her abdomen was soft obese nontender and
nondistended.

LABORATORY VALUES UPON ADMISSION TO THE HOSPITAL: White
blood cell count of 10000 hematocrit of 32 platelet count
of 201. Sodium of 148 potassium 3.3 chloride 110 CO2 21
BUN 42 creatinine 3.7 glucose of 277.

Patient initially had an echocardiogram which revealed a left
ventricular ejection fraction of 60% and moderate tricuspid
regurgitation.

Chest x-ray on admission to the hospital revealed a small
left pleural effusion DISEASE and questionable congestive heart failure DISEASE pattern.

It was noted that the patient's Vancomycin and tobramycin
levels were quite low upon admission to the hospital and she
was restarted on both of those medications.

On [**6-7**] hospital day two the patient underwent a
Plastic Surgery consultation due to persistent sternal wound
infection DISEASE which had previously been healing now showing
signs of infection DISEASE . Patient was also noted to have
Clostridium difficile colitis DISEASE for which she had been placed
on intravenous Flagyl.

The patient was ultimately taken to the operating room on
[**2195-6-9**] after transesophageal echocardiogram the
previous day ruled out endocarditis DISEASE . In the operating room
the patient underwent a limited sternal wound debridement and
drainage of some fluids at the inferior portion of her wound.

Postoperatively the patient returned to the Surgical
Intensive Care Unit where she has had problems with
intermittent hypotension DISEASE requiring IV Neo-Synephrine drip.
Patient continued on tube feeds via her jejunostomy tube
which was previously placed during her previous admission
which she had been tolerating well. She was still on the
ventilator on varying levels of pressure support in the CPAP
mode which she had tolerated well on 50% FIO2.

Patient received a few units of packed red blood cells over
the course of the next few days due to drifting hematocrit.
Patient's sternal wound had remained clean and ultimately a
VAC dressing was placed in the sternal wound area on [**2195-6-18**]. The patient was maintained on 3x a week hemodialysis
treatments on Monday Wednesday Friday and has been
tolerating those treatments well. Patient's pressure support
was ultimately weaned from 12 to 5 and she has remained on
pressure support of 5 for the past few days with an FIO2 of
50% and a PEEP of 5 as well and has remained stable on those
ventilator settings.

The patient has had short bouts of trache mask trials but
does get tachypneic DISEASE after approximately 30 minutes. Patient
also required bedside repositioning of her jejunostomy tube
which was done in the Intensive Care Unit successful with no
sequelae from that patient. The patient has remained with
stable hemodynamic parameters. Has been tolerating her tube
feeds has remained on minimal ventilator supports and she
is ready to be transferred to rehabilitation facility to
progress with Physical [**Hospital 966**] rehabilitation and ultimate
weaning from a ventilator.

The patient's condition day on [**2195-6-19**] is as follows:
temperature is 99.0 heart rate is 88 in normal sinus rhythm
respiratory rate varies from 18-24. Her blood pressure is
114/46. On the ventilator the patient is in a CPAP mode
with 5 of PEEP 5 of pressure support and 50% of O2 with a
most recent blood gas being 7.41 41 73 27. Other
laboratory values from today [**6-19**] are as follows: White
blood cell count 5.6 hematocrit of 35.8 platelet count of
206. PT 13.9 INR 1.3 PTT 29.9 sodium 132 potassium 5.3
chloride 99 CO2 24 BUN 64 creatinine 3.6 glucose 124.

Patient's most recent chest x-ray was on [**2195-6-8**] which
showed a chronic left pleural effusion DISEASE .

Most recent cultures include a sputum culture from [**6-8**]
which revealed MRSA Pseudomonas as well as Serratia.
Patient is previously cultured MRSA from both her leg wound
and her sternal wound. Stool on [**6-10**] is positive for
Clostridium difficile DISEASE . Urine on [**6-12**] is positive for
proteus and enterococcus and her sternal wound swab on [**6-9**] had rare growth of diphtheroids.

Physical examination today: The patient is awake alert and
responsive. She has coarse breath sounds DISEASE bilaterally. Her
chest wound is clean with a VAC dressing in place. Her
abdomen is soft obese and nontender. Her extremities are
with 2Admission Date: [**2195-6-29**] [**Year (4 digits) **] Date: [**2195-7-2**]

Date of Birth: [**2120-5-13**] Sex: F

Service:

ADMISSION DIAGNOSES: 1) Anoxic DISEASE brain injury. 2) End-stage
renal disease DISEASE on hemodialysis. 3) Sternal wound. 4)
Diabetes DISEASE . 5) Respiratory distress DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
female status post a long hospitalization at [**Hospital1 18**]
culminating in CABG x 4 porcine AVR aspiration infection DISEASE
sternal wound infection saphenous vein site infection
status post a G-tube with abdominal wall necrosis DISEASE status
post J-tube ARF DISEASE requiring hemodialysis. The patient
eventually discharged on [**2195-5-28**]. Then readmitted on
[**2195-6-6**] for fever DISEASE to 103. In VICU DISEASE for sternal wound
infection DISEASE and transferred to [**Hospital **] Rehab.

At [**Hospital1 **] two days prior to admission per report the
patient had a PEA arrest DISEASE status post epinephrine. The
patient went into V-fib arrest status post 100 mg joule
shock DISEASE which converted into A-fib. The patient was
transferred to [**Hospital 8**] Hospital late PM on [**2195-6-28**]. The
patient there was continued on vent. Chest x-ray and CT
showed a bilateral lower lobe consolidation and left upper
lobe consolidation. The [**Year (4 digits) **] report from [**Hospital 8**]
Hospital attributed mucous plugging and vent associated
pneumonia DISEASE leading to PEA arrest DISEASE . Also contributing were
elements of hyperkalemia hypoxia DISEASE and hypovolemia DISEASE .

The patient had initially had episodes of SVT DISEASE in the 70s-90s
which responded to 250 of normal saline. The patient
remained in atrial fibrillation DISEASE and spontaneously converted
to sinus. She was transferred to [**Hospital1 18**] for continuity of
care.

PAST MEDICAL HISTORY: 1) Coronary artery disease DISEASE status
post CABG x 4 - LIMA to LAD SVG to diagonal SVG to OM
sequential 2) AVR porcine 3) End-stage renal disease DISEASE on
hemodialysis 4) Diabetes DISEASE 5) OSA DISEASE 6) OA DISEASE 7) Vertigo DISEASE 8) Skin
cancer DISEASE 9) History of abdominal hernia DISEASE repair 10) Uterine
cancer DISEASE status post TAH DISEASE 11) Obesity DISEASE 12) Hypertension DISEASE 13)
Status post esophageal dilatation 14) Status post gastric
bypass with ventral hernia DISEASE 15) High cholesterol.

MEDS ON TRANSFER: 1) prevacid 2) Reglan 3) Zofran 4)
iron 5) zinc sulfate 6) amiodarone 7) Vitamin C 8)
tobramycin 9) vancomycin 10) heparin 11)
................... 12) epogen.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: The patient is a rehab patient at [**Hospital1 **].
She has three sons.

FAMILY HISTORY: Mother and grandmother died of diabetes DISEASE .

EXAM DISEASE : Temperature 101 heart rate 85 blood pressure 103/42
respiratory rate 44 98% on vent IFMV 600x14 FIO2 0.5
pressure support 10 PEEP 5. General - an elderly woman
chronically ill in no acute distress. HEENT - pupils
equally round and reactive to light minimally. OP - mucous
membranes moist evidence of some EOMI. In general patient
not responsive. Neck - trach no JVD. Lungs - crackles at
the left lower zone. Cardiovascular - regular rate and
rhythm systolic murmur I/VI ejection murmur DISEASE . Abdomen -
positive bowel sounds nontender nondistended. Evidence of
sternal wound draining suctioned with VAC. Evidence of a
J-tube entrance of a ventral hernia DISEASE wound and evidence of a
wound under the left breast. Extremities - left heel eschar.
Right leg saphenous vein site erythematous. Neuro - patient
grimaces to sternal rub does not follow commands. She has
positive Snell positive grasp. No decreased deep tendon
reflexes in lower extremities. Babinski equivocal.

LABS FROM [**6-29**] FROM [**Hospital1 **]: White blood cell count 12
hematocrit 35.9 platelets 209 N 87 L 8 M 3 E 1.
Electrolytes - 128/5.7 102/20 47/3.5 243. CT of the head
showed no bleed. CT of the chest showed left upper lobe
infiltrate bilateral pleural effusions DISEASE and bilateral
consolidation. ABG - 7.26 45 91 INR 1 T4 5.4 ALT 11
AST 21 alk phos 165 total bili 0.7.

LABS AT [**Hospital1 18**] [**6-29**]: White blood cell count 8.5 hematocrit
31.9 platelets 193 N 86 L 8 M 5. Electrolytes - sodium
144 K 3.3 chloride 107 bicarb 27 BUN 27 creatinine 2.5
platelets 150 lactate 1.4 ..................... ABG -
7.42 45 109 on FIO2 of 50%. Tobra level and vanc level
pending.

HOSPITAL COURSE: Please see previous [**Hospital1 18**] hospitalization
summaries. Outside hospital [**Hospital1 8**] report head CT -
chronic degenerative DISEASE changes. On [**6-29**] chest CT report - no
PE bilateral lower lobe consolidation effusions left upper
lobe consolidation. Echo from [**6-8**] - LVEF of greater than
55% RV function reduced mild MR.

ASSESSMENT AND PLAN: The patient was a 75-year-old woman
with coronary artery disease DISEASE CABG end-stage renal disease DISEASE
diabetes DISEASE status post a PEA arrest DISEASE V-fib A-fib now in
sinus likely secondary to hypoxia hyperkalemia DISEASE .

1) CARDIAC - Status post arrest. Patient with history of
arrest. The patient was ruled out by enzymes. The arrest
was likely a combination of hypoxia DISEASE and mucous plugging as
well as metabolic with possible hyperkalemia DISEASE and
hypercalcemia DISEASE . The patient has a history of a normal echo.
The patient's rhythm was in sinus. The patient was continued
on 200 mg po qd. The patient placed on telemetry and
monitored in the MICU. Monitored electrolytes and in's and
out's. The patient remained stable throughout her
hospitalization. The patient's sternal wound placed to VAC.

2) PULMONARY: Patient with a history of being vent and trach
dependent. Patient treated with vanc tobra ceftaz and
Flagyl given history of vent-associated given history of
antibiotic resistant organisms. Sputum showed gram-negative
rods. We will await final sensitivities from sputum. The
patient's O2 sats remained stable throughout her
hospitalization.

3) RENAL: Patient with end-stage renal disease DISEASE on
hemodialysis. The patient obtained hemodialysis in-house.

4) ENDOCRINE: Patient with diabetes DISEASE on sliding scale. The
patient was maintained on sliding scale. Thyroid level was
checked and normal.

5) ID: Patient had one episode of being febrile DISEASE on [**6-30**].
The patient since then afebrile. The patient's blood urine
sputum cultures pending. Patient with several wounds
nonhealing DISEASE in nature. The patient had no evidence of active
pus or drainage from any of the sites. The patient's sternal
wound is set to the VAC.

6) NEURO: Patient evaluated by neuro in-house given change
in mental status status post PEA arrest. The patient's
initial diagnosis was most likely hypoxic damage DISEASE resulting
from hypoxic event. The patient's head CT showed no changes.
MRI was obtained. EEG was obtained.

7) HEME: Patient on Epogen and hemodialysis.

8) FEN: The patient's electrolytes were monitored in-house.
Peripheral - Patient maintained on subcu heparin Protonix.
Lines - patient with left Quinton right subclavian
peripherals.

9) CODE: Patient remained full.

PLAN: [**Month/Year (2) **] was discussed with family and PCP.
[**Name10 (NameIs) **] to rehab. Patient was also seen by a social worker
in-house. Patient discharged to rehab.

[**Name10 (NameIs) 894**] CONDITION: Poor.

[**Name10 (NameIs) 894**] DIAGNOSES: 1) Anoxic DISEASE brain injury. 2) End-stage
renal disease DISEASE on hemodialysis. 3) Diabetes DISEASE . 4) Status post
pulseless DISEASE electrical activity.




[**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 968**]

Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36

D: [**2195-7-1**] 12:17
T: [**2195-7-1**] 11:52
JOB#: [**Job Number 969**]
Admission Date: [**2152-10-2**] Discharge Date: [**2152-10-11**]


Service: MEDICINE ONCOLOGY

HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a history of metastatic melanoma DISEASE with known metastases
to the liver and lung who status post resection in the 90s
with recurrence in [**2146**] status post treatment with Taxol.

She presented to the Emergency Room on [**2152-10-3**]
with altered mental status decreased p.o. intake confusion DISEASE
and headache DISEASE over several weeks and was found to have three
mass lesions in her brain on head CT.

The patient was started on Decadron as well as Dilantin. In
the Emergency Room she became hypertensive DISEASE and was sent to
the SICU. She was maintained on Nipride GTT.

In the Intensive Care Unit the patient was weaned off
Nipride and then changed to Labetalol Hydralazine. The patient
was also noted to have cellulitis DISEASE on her left knee and was
initially maintained on Vancomycin and later changed to Keflex.

The patient was also evaluated by Radiation/Oncology and it
was decided that the patient would received a total of seven
treatments of whole brain radiation therapy in conjunction
with Decadron as well as Dilantin.

During her Intensive Care Unit stay the patient had
increased alertness and was more oriented although she does
have a history of baseline dementia DISEASE .

PAST MEDICAL HISTORY: Metastatic melanoma DISEASE status post
resection in [**2138**] with recurrence in [**2146**] status post
treatment with Taxol. History of paroxysmal atrial
fibrillation DISEASE with anticoagulation in the past. Status post
PCM for sinoatrial dysfunction DISEASE . History of coronary artery
disease status post myocardial infarction DISEASE in [**2143**]. MIBI in
[**2152-6-23**] showed an ejection fraction of 50%. History of
hypercholesterolemia DISEASE . History of hypertension DISEASE
osteoarthritis cellulitis DISEASE . Status post skin graft. Peptic
ulcer disease DISEASE . History of bladder cancer DISEASE . Chronic renal
insufficiency.

ALLERGIES: AMOXICILLIN OXACILLIN AND PERCOCET REACTIONS
UNKNOWN.

MEDICATIONS ON ADMISSION: Imdur 30 mg Warfarin Lasix 20
q.d. Calcium Carbonate 1500 q.d. Vitamin D 4000 q.d.
Colace 100 mg b.i.d. Protonix 40 q.d. Dietrol 2 mg b.i.d.
Labetalol 300 mg b.i.d. Lipitor 10 mg p.o. q.d.

SOCIAL HISTORY: The patient is a home health aide. Husband
died three months ago. She walks but recently was unable to
do so. She otherwise has a very close family.

FAMILY HISTORY: On maternal side there is a history of
diabetes DISEASE as well as hypertension DISEASE .

PHYSICAL EXAMINATION: Vital signs: Temperature 96.5Admission Date: [**2195-8-12**] [**Year (4 digits) **] Date: [**2195-8-15**]

Date of Birth: [**2120-5-13**] Sex: F

Service: MICU

CHIEF COMPLAINT: Sepsis.

HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
female with an extremely complicated past medical history
including coronary artery bypass graft times four atrial
ventricular valve replacement in [**1-12**] and a precipitously
difficult postoperative course. The patient has never been
weaned from her ventilator and has had multiple ventilator
associated pneumonias DISEASE particularly most recently with
pseudomonas Serratia and Klebsiella. The patient has end
stage renal disease DISEASE and history of gastrointestinal bleed DISEASE
secondary to gastritis DISEASE and esophagitis DISEASE .

Most recently the patient was discharged from this hospital
to rehabilitation in early [**Month (only) 547**] only to come back with
fevers DISEASE and ultimately grew out Methicillin resistant
Staphylococcus aureus wound infection DISEASE requiring debridement
on [**2195-5-28**]. The patient returned to rehabilitation
[**2195-6-22**] where she sustained a pulmonary embolus arrest DISEASE
received Epinephrine and electrical conversion. The patient
was noted to have decreased responsiveness post code
attributed to anoxic DISEASE brain injury per neurology. She was
transferred back to [**Hospital **] Rehabilitation where she
underwent vigorous physical therapy.

On [**2195-8-1**] per family she had a fever DISEASE of 103 with culture
peripherally and from her dialysis catheter. Both grew out
Methicillin resistant Staphylococcus aureus. The patient was
started on a course of Vancomycin with only low grade
temperature. She became lethargic on [**2195-8-9**] and was
unable to tolerate hemodialysis due to hypotension DISEASE systolic
blood pressure in the 70s. The patient briefly improved
postdialysis on [**2195-8-10**] as did her mental status but then
became increasingly lethargic with heart beats in the 130s
blood pressure 80 over palpable and was transferred over to
[**Hospital1 69**] for further management.

On arrival the patient was noted to be extremely febrile DISEASE
hypotensive tachypneic DISEASE . The patient received an A line and
right internal jugular central line for monitoring and fluid
resuscitation. The patient's course was complicated by her
poor toleration of hemodialysis secondary to hypotension DISEASE and
was started on pressors of Levophed and ultimately required
an addition of vasopressor. The patient was becoming
increasingly somnolent and had not defervesced at this time
despite the addition of multiple antibiotic therapy Flagyl
Ceftriaxone Vancomycin and Tobramycin.

CT of the abdomen and chest showed no frank abscess or fluid
collection. Flagyl was ultimately discontinued as decreased
probability of anaerobic infection DISEASE . Cultures at outside
hospital showed multidrug resistant organisms including
Methicillin resistant Staphylococcus aureus. Transesophageal
echocardiogram was obtained to rule out endocarditis DISEASE and it
was negative showing ejection fraction of 55%. Left Hickman
catheter with [**Hospital1 **] as probable source of infection DISEASE .
Foley was placed at this time. The patient was anuric yet
10cc of purulent material was noted. The patient was now
growing gram positive cocci in pairs and clusters from two
different sites the Hickman and/or previous PICC line. She
was increasing her pressor requirement and was hypotensive DISEASE
despite two liters of fluid.

She was started on Dopamine in addition to her Levophed and
vasopressors. Throughout the day the patient's systolic
blood pressure decreased to the 80/30. By [**2195-8-14**] she was
back on EC vent control. The patient was noted at 3:43 a.m.
on [**2195-8-15**] to have an episode of asystole DISEASE . The family was
at bedside as well throughout the night. The pupils were
noted to be fixed and dilated and unresponsive. Ventilation
was discontinued and spontaneous respirations were not
observed. The patient was declared dead at 3:43 a.m. The
family declined autopsy.




DR.[**Last Name (STitle) 970**][**First Name3 (LF) 971**] 12-888

Dictated By:[**Last Name (NamePattern1) 972**]

MEDQUIST36

D: [**2195-8-15**] 11:51
T: [**2195-8-18**] 20:47
JOB#: [**Job Number 973**]
Admission Date: [**2177-8-20**] Discharge Date: [**2177-8-26**]

Date of Birth: [**2121-10-22**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Diarrhea DISEASE X 2.5 weeks abdominal pain fatigue DISEASE

Major Surgical or Invasive Procedure:
[**2177-8-20**]: Right-sided internal jugular venous catheter

History of Present Illness:
55 year-old female presents with 2/5 week history of non-bloody
diarrhea DISEASE . Patient states that diarrhea DISEASE is often preceeded by
right and left lower quadrant cramping and discomfort. Symptoms
are relieved with voiding and evucation. She denies fever DISEASE
nausea DISEASE and/or emesis DISEASE . She reports two episodes of chills DISEASE . She
presents today with fatigue DISEASE . She denies abdominal distension DISEASE or
hematesis. Denies urinary symptoms DISEASE . She was recently seen by her
Primary Care Physician for evaluation of diarrhea DISEASE and by report
stool O&P cultures were negative.

Past Medical History:
Seizure disorder DISEASE
Insulin Dependent Diabetes Mellitus DISEASE (x4 years on Lantus)
Vitiligo DISEASE
[**2170**]: Stiff person syndrome DISEASE treated with Valium
hypercholesterolemia DISEASE
Bronchitis DISEASE
Anemia DISEASE
Constipation DISEASE
.
PSH DISEASE
D&C
Pyloric stenosis DISEASE at age 6 weeks


Social History:
Works in human resources: Department of Labor DISEASE for the State
Denies tobacco ETOH IV drug use
Independent in activites of daily living
Use of assistive devices at homeAdmission Date: [**2151-5-25**] Discharge Date: [**2151-5-31**]


Service: MEDICINE

Allergies DISEASE :
Demerol

Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Lethargy DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
82 year old male with past medical history of coronary artery
disease atrial fibrillation DISEASE type 2 diabetes BPH chronic
kidney disease DISEASE and gout DISEASE who presents with intermittent confusion DISEASE
and high fevers DISEASE . The patient is [**First Name3 (LF) 595**] speaking only generally
sleepy but family (son) recounts that the patient had difficulty
voiding 6/1-2/[**2150**]. At the time he endorsed urinating
frequently but small amounts each time (Admission Date: [**2185-10-25**] Discharge Date: [**2185-11-2**]

Date of Birth: [**2120-2-23**] Sex: M

Service:

CHIEF COMPLAINT: Dyspnea on exertion.

HISTORY OF PRESENT ILLNESS: Patient is a 65-year-old man
recently evaluated for worsening dyspnea DISEASE on exertion. The
patient was first evaluated for dyspnea DISEASE on exertion back in
[**2183-9-28**]. At that point he was found to have mild
left coronary artery disease DISEASE as well as a totally occluded
right coronary artery with good collaterals. He was also
noted to have a moderate mitral regurgitation DISEASE . He was
managed medically for this condition.

During the course of the year [**2184**] the patient noted
progressive decrease in his activity tolerance. After work
up it was determined that the patient was in need of repair
of his mitral valve as well as coronary artery bypass
grafting.

PAST MEDICAL HISTORY:
1. Myocardial infarction DISEASE .
2. Coronary artery disease DISEASE .
3. Possible chronic obstructive pulmonary disease DISEASE .
4. Depression.
5. Hypertension.
6. Hyperlipidemia.
7. Valve disease DISEASE .
8. Remote pleurisy DISEASE .
9. Arthritis.
10. Possible prior CVA DISEASE .
11. Recovered alcoholic (has not drank in 16 years).

PAST SURGICAL HISTORY:
1. Umbilical hernia DISEASE repair.
2. Cataract surgery.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS:
1. Vistaril.
2. Lipitor.
3. Multivitamins.
4. Aspirin.
5. Escitalopram.

HOSPITAL COURSE: Patient was admitted to the Medical Center
on [**2185-10-25**] and taken to surgery for coronary artery bypass
graft and mitral valve repair. Surgery was performed without
complications and patient thereafter was transferred to the
CSRU. Later on the day of surgery the patient received two
units of packed red blood cells for a hematocrit of 21.2.

Patient required pacing through postoperative day #1 and #2
to maintain an adequate heart rate. He was successfully
extubated on postoperative day #1 even though he continued
to be wheezy DISEASE with significant productive cough DISEASE during his
entire stay in the CSRU.

The patient as stable enough for transfer to the
Cardiothoracic Surgery Floor DISEASE late on postoperative day #2.
Late on postoperative day #5 the patient went into atrial
fibrillation DISEASE . His heart rate was eventually successfully
controlled with Metoprolol and Amiodarone. The patient had
periods of persistent tachycardia DISEASE during postoperative day
#6. Decision was made to initiate anticoagulation with
heparin as well as Coumadin. The patient remained stable and
without complaints during postoperative day #7.

On postoperative day #8 the patient was deemed stable for
discharge to home. The decision was made to discontinue the
patient's Amiodarone prior to discharge given decrease in his
heart rate to the 50s. He remained in sinus rhythm.

Following discharge it was planned the patient would receive
a visit from a visiting nurse two days following discharge
for an INR check. The results of the INR check was to be
faxed to the patient's cardiologist. The patient was to call
his cardiologist on discharge day #2 for instructions on
further Coumadin doses. The patient was to take 10 more days
of Lasix following discharge since he was still significantly
above his admission weight.

CONDITION ON DISCHARGE: Stable.

DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Escitalopram 10 mg p.o. q.d.
3. Atorvastatin 200 mg p.o. q.d.
4. Percocet.
5. Enteric coated aspirin 325 mg p.o. q.d.
6. Potassium Chloride 20 mEq p.o. b.i.d.
7. Lasix 40 mg p.o. b.i.d.
8. Coumadin 5 mg p.o. q.d. times two days.

FO[**Last Name (STitle) 996**]P:
1. Patient is to follow up with Dr. [**Last Name (Prefixes) **] in clinic
four weeks following discharge.
2. Patient was to contact his cardiologist's office two days
following discharge for further guidance on his Coumadin
dosing as well as to schedule a follow up appointment.
3. The patient was to contact his primary care physician's
office for a follow up appointment in approximately three
weeks.




[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]

Dictated By:[**Name8 (MD) 997**]
MEDQUIST36

D: [**2185-11-2**] 14:20
T: [**2185-11-2**] 14:37
JOB#: [**Job Number 998**]
Admission Date: [**2186-2-4**] Discharge Date: [**2186-2-21**]

Date of Birth: [**2126-9-17**] Sex: F

Service: NEUROLOGY

Allergies DISEASE :
Haldol / Prozac / Paxil / Sinemet Cr

Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
FTT


Major Surgical or Invasive Procedure:
PEG placement

History of Present Illness:
The pt is a 59 year-old right-handed with progressively
worsening stiffness weakness DISEASE and dysarthria DISEASE since [**2183**] who is
sent in from her rehab for generalized weakness decline and
difficulty eating. The patient is followed by Dr. [**First Name (STitle) 951**] in the
movement disorders DISEASE division who notes an extensive negative
workup in his most recent assessment of [**2186-1-10**] (see below).
Per
the record the stiffness started after a fall on ICE in [**2183**].
She
was admitted 7/21-26/07 for left leg dystonia DISEASE . Possible
etiologies considered at that time included hereditary spastic DISEASE
paraparesis Parkinsons DISEASE and multiple systems atrophy DISEASE . Little
evidence could be found for any of these disorders.


An new EMG today demonstrated a generalized moderately severe
chronic and ongoing disorder of motor neurons DISEASE or their axons.


The patient has been on tizanidine flexeril baclofen sinemet
and artane - none with particularly significant effect.



Past Medical History:
depression DISEASE
rotator cuff injury
osteopenia DISEASE
colectomy
appendectomy
Per Dr.[**Name (NI) 1033**] [**2186-1-10**] note:
Admission Date: [**2124-4-24**] Discharge Date: [**2124-5-3**]


Service: Cardiothoracic Surgery

HISTORY OF PRESENT ILLNESS: This is an 84-year-old male
referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] for evaluation of surgical
options for severe aortic stenosis DISEASE and coronary artery
disease.

The patient experienced a near-syncopal episode in [**2124-1-8**]Admission Date: [**2143-3-10**] Discharge Date: [**2143-3-29**]

Date of Birth: [**2097-8-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Bactrim Ds / Indomethacin

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
1) Intubation with mechanical ventilation
2) Bronchoscopy

History of Present Illness:
45 yo man with h/o HIV who p/w 4 days of cough DISEASE productive of
brown sputum as well as left sided pleuritic CP. He denied
hemoptysis N/V DISEASE or abdominal pain DISEASE .
*
In the ED the patient became hypoxic with an O2 sat of 80% on
RA DISEASE which improved to 91% on NRB. He was also tachypneic. The
patient was intubated. He was tachy to the 130's BP 133/75
with a lactate of 4.0. Patient became hypotensive DISEASE at 70/35
after intubation/sedation. Levophed was started. Unable to
adequately sedate on Propofol gtt.


Past Medical History:
HIV/AIDS (CD4Admission Date: [**2144-2-4**] Discharge Date: [**2144-2-7**]

Date of Birth: [**2097-8-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Bactrim Ds / Indomethacin / Ciprofloxacin / Linezolid

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
productive cough DISEASE night sweats fevers DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Pt is a 46 yo M with hx of HIV/AIDS (last CD4 204 VL 40600 on
[**2143-12-12**] not on HAART) Hepatitis C peripheral neuropathy DISEASE with
chronic pain DISEASE on narcotics contract who now presents with 3 week
history of decreased po intake malaise night sweats fatigue
productive cough DISEASE of green sputum chills. He also states that
he developed chest pain DISEASE on his right side worse with deep
inspiration and with coughing. Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]

Date of Birth: [**2120-5-13**] Sex: F

Service:

ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status status post anoxic brain
injury. The EEG showed diffuse encephalopathy DISEASE and the MRI
showed no severe edema DISEASE . The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes was able to slightly move her
extremities and interact with the family.

2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.

3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections DISEASE . The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.

4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.

5. Hematology: The patient's hematocrit remained stable.

6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.

7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].





[**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 968**]

Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36

D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
Admission Date: [**2145-12-9**] Discharge Date: [**2145-12-16**]

Date of Birth: [**2097-8-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Bactrim Ds / Indomethacin / Linezolid

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
found down

Major Surgical or Invasive Procedure:
IntubatedAdmission Date: [**2194-7-18**] Discharge Date: [**2194-7-25**]

Date of Birth: [**2123-12-24**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Atorvastatin / Penicillins / Codeine

Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
SOB decreased urine

Major Surgical or Invasive Procedure:
Hemodialysis
Placement of a R IJ catheter
Placement of a R subclavian tunneled dialysis line


History of Present Illness:
Ms. [**Known lastname 2251**] is a 70yoF with h/o dilated cardiomyopathy DISEASE [**1-1**]
aortic outflow obstruction DISEASE AICD s/p VT DISEASE CAD COPD DISEASE (on home O2)
who presented with decreased UO and SOB now transferred from
medicine service to CCU for hypotension DISEASE . Pt is currently
somnolent and unable to provide a detailed history so details
are obtained from OMR and Atrius records. Pt saw NP in complex
care clinic on [**7-10**] at that time felt well overall c/o dry
cough DISEASE but denied SOB peripheral edema DISEASE . At that time her weight
was recorded at 185 lbs (dry weight is estimated at 184 lbs). On
[**7-17**] she called the CCC office c/o minimal urine output (Admission Date: [**2146-1-14**] Discharge Date: [**2146-1-28**]

Date of Birth: [**2097-8-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Bactrim Ds / Indomethacin / Linezolid

Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
seizures DISEASE mental status changes

Major Surgical or Invasive Procedure:
Lumbar puncture


History of Present Illness:
The patient is a 48M w/ HIV/AIDS/HCV/IVDA sent from [**Hospital1 1099**] Rehab for evaluation of 2 witnessed tonic-clonic DISEASE
seizures DISEASE . Seizures DISEASE occurred on evening [**2146-1-13**] lasted 30
seconds - 1 minute resolved spontaneously. First seizure DISEASE
occured while he was being cleaned up second seizure DISEASE occured
while family member (motherAdmission Date: [**2132-3-28**] Discharge Date: [**2132-4-9**]

Date of Birth: [**2054-2-21**] Sex: M

Service: ORTHOPAEDICS

Allergies DISEASE :
Levaquin

Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
Hip and patellar fracture DISEASE

Major Surgical or Invasive Procedure:
ORIF of right patella fx
ORIF of right femoral neck fracture


History of Present Illness:
Briefly Mr. [**Known lastname 1104**] is a 78 year old male with extensive medical
history who uses a RLE prosthesis for ambulation s/p R BKA from
PVD DISEASE who presents s/p fall when his prosthesis slipped out of
place found to have R patellar and non-displaced fracture DISEASE of
the R femoral neck here for possible orthopedic surgery. His
medical problems notably include CAD s/p CABG in [**2117**] MI [**2123**]
MIBI with fixed and reversible defects in [**2129**] CHF DISEASE with EF 20%
PVD DISEASE s/p R BKA with b/l iliac stents AAA found to be 5.4 x 5.0
cm on recent abdominal US paroxysmal atrial fibrillation DISEASE
bovine AVR and CRI on coumadin for his iliac stents and PAF.

Patient reports that at baseline he is able to walk about 2
blocks and activity is limited by SOB. He feels SOB getting
out of bed in the morning. He is able to climb a flight of
stairs without difficulty. He denies orthopnea DISEASE or LE edema DISEASE . No
recent weight gain DISEASE .

Past Medical History:
1) CAD s/p CABG [**2117**] MI [**2123**]
2) AS s/p AVR [**2123**] (bovine)
3) PVD DISEASE s/p R BKA and b/l iliac artery stents
4) Carotid stenosis DISEASE s/p R CEA
5) h/o C. Diff
6) h/o MRSA
7) CHF DISEASE class [**Last Name (LF) 1105**] [**First Name3 (LF) **] 30%
8) AAA 5 x 5.4 cm
9) S/P AICD
10) Hypercholesterolemia DISEASE
11) CRI (baseline approx. 1.3)
12) PAF

Social History:
Lives at home alone independent. Quite smoking 8 years ago but
50 pack year smoking hx.

Family History:
Non-contributory

Physical Exam:
98.2 68 100/48 RR15 98% on RA DISEASE
Gen: Cachectic appearing elderly male resting comfortably in
bed appearing in pain DISEASE with movement.
Neck: No JVD.
Cor: RR normal rate no m/r/g.
Lungs: CTA b/l.
Abd: NABS soft NT/ND DISEASE
Extr: No c/c/e. R BKA. Swollen erythematous R knee
exquisitely tender. Trace PT on the L.

Pertinent Results:
[**3-28**] AP LATERAL AND SUNRISE VIEWS OF THE PATELLA: No prior
studies are available for comparison. There is a horizontal
fracture DISEASE through the patella with 1.2 cm of displacement of the
fragments anteriorly. There is a small joint effusion DISEASE . There are
changes from prior BKA and extensive [**Month/Year (2) 1106**] calcifications DISEASE
are present.
IMPRESSION: Horizontal patellar fracture DISEASE with 1.2 cm of
displacement anteriorly.

[**3-28**] PELVIS AND RIGHT HIP THREE VIEWS: There is a transverse
lucency through the femoral neck which may represent a
nondisplaced fracture DISEASE . No other fractures DISEASE or dislocations DISEASE are
identified. Degenerative changes of the SI and hip joints DISEASE are
noted. There is diffuse demineralization. Extensive [**Month/Year (2) 1106**]
calcifications DISEASE and iliac stents are noted.
IMPRESSION: Transverse lucency through the femoral neck which
may represent a nondisplaced fracture DISEASE .

[**3-28**] CT PELVIS: There is a nondisplaced fracture DISEASE of the
proximal right femoral neck. No other fractures DISEASE or dislocations DISEASE
are identified. There is diffuse osteopenia DISEASE . There is a small
amount of high attenuation fluid within the right hip joint
space which may represent a small amount of hemorrhage DISEASE .
Extensive [**Month/Year (2) 1106**] calcifications DISEASE are seen as are bilateral
iliac stents. Visualized portions of the pelvis are
unremarkable. Soft tissue structures are within normal limits.
IMPRESSION: Nondisplaced fracture DISEASE of the right femoral neck.


Brief Hospital Course:
78 year old male with extensive medical history notably
including CAD s/p CABG in [**2117**] MI [**2123**] MIBI with fixed and
reversible defects in [**2129**] CHF DISEASE with EF 20% PVD DISEASE s/p R BKA with
b/l iliac stents AAA found to be 5.4 x 5.0 cm on recent
abdominal US paroxysmal atrial fibrillation DISEASE who uses a RLE
prosthesis for ambulation s/p R BKA who presents s/p mechanical
fall with R patellar and R femoral neck fractures DISEASE here for
orthopedic surgery.

1) Ortho: Patient is high risk for surgery however per ortho
surgery will not be extensive could be completed in relatively
short time frame possibly under spinal anesthesia only.
Awaiting cardiolgy DISEASE consult for estimate of operative risk given
recent MIBI with reversible defects in all territories and cath
with 3VD. Patient willing to accept 25-30% chance of operative
mortality. [**Year (4 digits) **] has seen patient and says o.k. for surgery.
Limiting factor may be INR as still 2.9 with 5 mg Vitamin K.
Another 5 mg given but may need FFP/platelets and given EF
30% would likely need to be done under controlled setting in
ICU in case of respiratory distress DISEASE . [**Month (only) 116**] defer until tomorrow.
Needs patellar surgery one way or another in order to ever be
able to use prosthesis again.

2) AAA: Seen by [**Month (only) 1106**]. Will try to get CTA during
hospitalization at some point though not now in setting of
worsened creatinine. [**Month (only) 116**] just be able to get abdominal US.
Appreciate [**Month (only) 1106**] consult. Outpatient repair of AAA.

3) CHF DISEASE : Class [**Last Name (LF) 1105**] [**First Name3 (LF) **] 20% in past though 30% on most recent
cath currently dry DISEASE on exam therefore holding lasix. If
patient doesn't go to surgery tonight will order food and will
likely order lasix then. Also will need lasix with any
FFP/platelets.
-Coumadin for goal INR [**1-10**]

4) PVD DISEASE : Bilateral iliac stents on coumadin therefore once INR
below 2 will have to start heparin drip.
--recheck INR post second dose of vitamin K if Admission Date: [**2179-1-29**] Discharge Date: [**2179-2-2**]

Date of Birth: [**2093-2-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
respiratory distress DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
85-year-old female atrial fibrillation schizophrenia dementia DISEASE
presents from nursing home with respiratory distress DISEASE .
.
The patient was in her usual state of health until this AM. At
that time she was found by nursing home staff in respiratory
distress with O2 sats of 70% on RA DISEASE . EMS was contact[**Name (NI) **] and she
was started on supplemental oxygen with NRB and O2 sats
responded to 98%. She was also noted to be hot (no document of
temperature) with cough DISEASE and green sputum. She was transported to
[**Hospital1 18**] ED.
.
In the ED initial vitals were: T 99.8 HR 90 BP 171/85 RR 28
SaO2 98% NRB15L. EKG with Afib DISEASE RVR to 130s and LVH DISEASE . SBP 180s.
WBC 16. BNP 12600. CXR interpreted as concerning for CHF DISEASE . She
was given nitroglycerin gtt diltiazem 10mg IV x2 aspirin
levofloxacin and furosemide 20mg IV x1. Per documents she
received 2L IVF. She was temporarily started on BIPAP however
did not tolerate well with hypotension DISEASE and tachycardia DISEASE . This was
discontinued and patient has been stable with vitals at transfer
of HR 105 BP 129/66 RR 26 SaO2 100% NRB.
.
Currently no distress although neglects left side. No movement
of left side. No respiratory distress DISEASE .
.
ROS: Unable to obtain.

Past Medical History:
- Atrial fibrillation/flutter DISEASE
- Schizophrenia DISEASE
- Anemia DISEASE
- h/o syncope DISEASE
- Dementia DISEASE
- Cardiomyopathy DISEASE
- Paroxysmal ventricular tachycardia DISEASE
- h/o C. Diff colitis DISEASE
- h/o peptic ulcer disease DISEASE
- PPD positive
- h/o cellulitis DISEASE


Social History:
Reportedly non-verbal although can communicate when in pain DISEASE .
Lives at [**First Name8 (NamePattern2) 1116**] [**Last Name (NamePattern1) **] Nursing Home. Normally can say name and
walks with shuffling gait. No known history of smoking.

Family History:
Unable to obtain.

Physical Exam:
ADMISSION EXAM DISEASE :
VS: T: 96.2 Ax BP: 171/81 HR: 123 RR: 24 O2sat: 99% NRB 15L
GEN: non-verbal no apparent distress some wasting DISEASE
HEENT: PERRL eyes deviated to right dry MM op without lesions
although limited view
Neck: no supraclavicular or cervical lymphadenopathy
apprecaited Admission Date: [**2114-5-11**] Discharge Date: [**2114-5-23**]

Date of Birth: [**2054-1-30**] Sex: F

Service: SURGERY

Allergies DISEASE :
Ace Inhibitors

Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Abd pain DISEASE and N/V DISEASE


Major Surgical or Invasive Procedure:
s/p right and left hemicolectomy

History of Present Illness:
60F with ESRD DISEASE s/p deceased donor renal transplant HTN DISEASE and
diverticulitis DISEASE who was initially admitted for worsening
abdominal pain DISEASE and N/V DISEASE and now presents to the [**Hospital Unit Name 153**] with
hypotension DISEASE after having a n ex-lap and bowel resection for a
perforated cecum. She has had approximately 3 episodes of
diverticulitis DISEASE in the past year which resolved with antibiotics.
She was planning to have an elective outpatient laparoscopic
colectomy given her frequent flares DISEASE . Prior to this admission
she reportedly had intermittent [**10-3**] abdominal pain DISEASE in the RLQ
and LLQ and significant nausea DISEASE and vomiting DISEASE she was unable to
keep down any POs for 48 hours prior to admission. This felt
worse than her prior diverticulitis flares DISEASE and she was admitted
for observation hydration and antibiotics. CT abd/pelvis at
admission showed pericolonic stranding but no e/o
diverticulitis DISEASE .

Since admission to the surgery service she was staretd on Cipro
and Flagyl for the colitis DISEASE seen on CT. Her abdominal pain DISEASE
acutely worsened on [**5-12**] and she described feeling a Admission Date: [**2131-10-16**] Discharge Date: [**2131-10-22**]

Date of Birth: [**2057-1-5**] Sex: M

Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: MR. [**Known lastname 1127**] is a 74 year old right
handed white male who presented to the Emergency Room with
headache DISEASE and difficulty speaking. He has a history of left
occipital arteriovenous malformation which was resected in
[**2131-4-10**] by Dr. [**Last Name (STitle) 1128**] at [**Hospital6 1129**] and
[**2130-12-11**]. He had residual right visual field deficit
related to his last bleed and surgery.

Yesterday in the late morning the patient began having a
severe constant headache DISEASE in the left occipital region and
associated increased in the size of his right visual field
defect and difficulty speaking. He denied any focal

REVIEW OF SYSTEMS: The patient denied fever chills nausea DISEASE
vomiting DISEASE or change in appetite. He has lost ten pounds over
the last ten months. He has no chest pain palpitations DISEASE or
shortness of breath no abdominal pain DISEASE no change in bowel or
bladder habits.

PAST MEDICAL HISTORY: 1. Left occipital arteriovenous
malformation DISEASE resected in [**2131-4-10**] at [**Hospital6 1130**] by Dr. [**Last Name (STitle) 1128**] on seizure DISEASE prophylaxis. 2.
Tonsillectomy.

ALLERGIES: The patient has no known drug allergies DISEASE .

MEDICATIONS ON ADMISSION: Trileptal 300 mg p.o.b.i.d. and
stool softener.

SOCIAL HISTORY: The patient is a retired sculptor. He is
married with one son and lives with his wife. [**Name (NI) **] has had no
recent alcohol use no tobacco or drug use.

PHYSICAL EXAMINATION: On physical examination the patient
had a blood pressure of 173/83 heart rate 74 and oxygen
saturation 100%. General: Patient appeared stated age
lying in bed. Head eyes ears nose and throat: Sclerae
white oropharynx clear DISEASE without lesions pupils equal round
and reactive to light. Neck: Supple no jugular venous
distention no bruits DISEASE no tenderness DISEASE . Lungs: Clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm normal S1 and S2 no murmur. Abdomen: Soft
nontender nondistended positive bowel sounds. Extremities:
Warm no cyanosis clubbing DISEASE or edema DISEASE peripheral pulses all
felt.

Neurologic examination: Awake alert and cooperative could
not name days of week forward and backward could not name
common or uncommon objects could point to objects when asked
but not letters or shapes calculation was deficient for
simple math could repeat numbers but not sentences could
not read or copy tests stereognosia and graphesthesia
present in right hand more than left. Speech: Could
initiate spontaneous speech with normal patterns and
pronunciation initially but had word finding difficultiesAdmission Date: [**2195-11-23**] Discharge Date: [**2195-12-2**]

Date of Birth: [**2127-7-17**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Ivp Dye Iodine Containing / Ativan

Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
hypoglycemia DISEASE

Major Surgical or Invasive Procedure:
Incision and drainage with resection of first metatarsal
[**2195-11-25**]
Wound closure [**2195-11-30**]


History of Present Illness:
Mr. [**Known lastname 1137**] is a 68yo M w/hx of DM2 DISEASE (A1c [**10-23**] 7.1%) afib on
coumadin chronic diabetic foot ulcers DISEASE h/o EtOH abuse and HTN DISEASE
who was sent in from his PCPs office with symptomatic
hypoglycemia DISEASE to 36 that has been ongoing for 3Admission Date: [**2108-2-17**] Discharge Date: [**2108-2-22**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
cardioversion

History of Present Illness:
83 y/o F with h/o MI s/p 4 vessel CABG CHF DISEASE mitral
regurgitation with worsening SOB and DOE over the last few
months. Pt reports that she is now able to walk much less than
a block without feeling short of breath and that this has
gotten worse in the last few months. However she denies an
acute worsening of shortness of breath/DOE prior to her
admission. Shortness of breath has not been associated with
wheezing DISEASE . No associated chest pain DISEASE . Pt notes paroxysmal
nocturnal dyspnea DISEASE about 2-3 episodes per night every night.
Denies orthopnea DISEASE and notes no changes in the number of pillows
used.

Denies fevers cough rhinorrhea chest pain diarrhea DISEASE or
dysuria DISEASE . Denies lower extremity edema. Denies palpitations DISEASE .
Reports that she has been taking her medications without missing
doses or running out of medicine. Denies any change in her
dietAdmission Date: [**2163-7-5**] Discharge Date: [**2163-7-15**]

Date of Birth: [**2097-6-11**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Bactrim / Ciprofloxacin / Codeine

Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
AMS

Major Surgical or Invasive Procedure:
None


History of Present Illness:
66 yo F with h/o PE renal failure DISEASE last Cr 5 seizure DISEASE d/o was
found down apparently x9 days after an unwitnessed seizure DISEASE . Pt
managed to crawl to window yell for help EMS arrived which
took pt to OSH. Pt has been recently hospitalized for malaise
[**Date range (1) 1163**]/[**2163**] and found to be in renal failure DISEASE which was
thought to be pre-renal DISEASE in the setting of poor PO intake
hypotension DISEASE from adrenal insufficiency DISEASE while off steriods. Her
Cr improved from 5.6 to 1.3 with IVF. She was also discharged on
cefuroxime for a UTI DISEASE abx to be completed [**6-24**]. Pt was
discharged to extended care facility on [**6-17**].
.
OSH: Arrived via EMS speech slurred DISEASE found pt in filthy appt
dried feces on legs cat feces and urine feces everywhere.
Initial VS 96.1 BP 84/50 HR 103 86%RA FS 73. Initial BUN/Cr
110/10.1 K 4.4 Alb 2.7 WBC 19.7 HCT 33.2 PLT 444 5%Bands
INR 2.1. Tox screen Admission Date: [**2191-4-24**] Discharge Date: [**2191-4-27**]


Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Age over 90 **]F with HTN Dyslipidemia DISEASE and Admission to [**Hospital1 882**] in [**2190-8-23**]
for acute pulmonary edema DISEASE presents from [**Hospital **] rehab c/o sob.
Pt lasix was noted to have been discontinued on end of [**3-16**]
to the fact that she had no peripheral edema DISEASE . Around 1am she
was found to be short of breath and O2 sat of 82% on Room air
and diaphoretic. Other vital signs were 98.4 107 136/74. She
was placed on 2L NC given albuterol and lasix 20mg PO. Her O2
sats increased to 88% and she put out 300cc of urine while en
route to [**Hospital1 18**] ED.
.
In the ED T:99.8 HR: 108 BP 147/87 RR: 32 91%NRB. Pt was
unable to speak in full sentences and T wave inversions in V4-6
trop 0.18 and proBNP: [**Numeric Identifier 1168**]. Placed on BIPAP and given
kayexalate 30mg PO for K of 6.0 aspirin 325mg PO x1 and lasix
20mg IV x1. Vancomycin 1gm an cefepime 2gm Nitro gtt started.
Pt diuresed 350cc of lasix in the ED. No effusion on bedside
(ED) echo. CXR showed vascular congestion DISEASE and bilateral pleural
effusions. Most Recent VS: 96 164/84 23 96% NRB DISEASE
.
On review of systems She denies recent fevers chills DISEASE or
rigors. She denies exertional buttock DISEASE or calf pain DISEASE . Denies DISEASE chest
pain nausea vomiting diarrhea DISEASE change in urnary habits URI
symptoms. All of the other review of systems were negative.
.
Positive for cough DISEASE for last month. Non-productive similar
during the day as well as at night could not tell us if
anything makes it better or worse.
.
Cardiac review of systems is notable for absence of chest pain DISEASE
dyspnea DISEASE on exertion paroxysmal nocturnal dyspnea orthopnea DISEASE
ankle edema palpitations syncope DISEASE or presyncope DISEASE .

Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes DISEASE Admission Date: [**2139-10-23**] Discharge Date: [**2139-10-31**]

Date of Birth: [**2063-1-13**] Sex: M

Service: TRANS [**Doctor First Name 147**]

HISTORY OF PRESENT ILLNESS: This is a 76 year old man who is
status post a right upper extremity AV fistula DISEASE three days
prior to admission who now presents with right upper
extremity swelling. This swelling DISEASE is associated with
significant pain DISEASE of his right arm and the patient does report
that prior to the surgery his arms were of similar caliber.

He denies fevers DISEASE or chills shortness of breath or abdominal DISEASE
pain DISEASE .

PAST MEDICAL HISTORY:
1. Diabetes mellitus DISEASE .
2. Peripheral vascular disease DISEASE .
3. End-stage renal disease DISEASE on hemodialysis.
4. Congestive heart failure DISEASE .
5. Coronary artery disease DISEASE .
6. Pulmonary hypertension DISEASE .
7. Benign prostatic hypertrophy DISEASE .
8. Sleep apnea.

PAST SURGICAL HISTORY:
1. Right radius cephalic AV fistula DISEASE in 06/[**2137**].
2. Right lobectomy for benign lung tumor DISEASE in [**2085**].
3. Revision of the right upper extremity AV fistula three
days prior to admission.

MEDICATIONS AT HOME:
1. Enteric coated aspirin 325.
2. Lipitor 40 mg once a day.
3. Colace 100 mg twice a day.
4. Nephrocaps one tablet once a day.
5. Lopressor.
6. Magnesium 125 mg once a day.
7. Imdur 60 mg once a day.
8. CPAP.
9. Insulin Humulin 70/30 33 units with breakfast and 14
units with dinner.

PHYSICAL EXAMINATION: Vital signs were temperature of 99.7
F.Admission Date: [**2195-4-14**] Discharge Date: [**2195-4-17**]

Date of Birth: [**2123-12-24**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Atorvastatin / Penicillins / Codeine / Oxycodone

Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Left leg swelling/edema

Major Surgical or Invasive Procedure:
None

History of Present Illness:
71F with history of CHF DISEASE CAD afib on coumadin ESRD on HD DISEASE and
COPD DISEASE presenting with pain swelling DISEASE and erythema DISEASE on the left
leg. Patient has had chronic ulcers DISEASE of the left and right leg
since last [**Month (only) 216**] and had been on vancomycin for 2 week course
completed on [**2195-2-19**]. Today noted increased swelling DISEASE and pain DISEASE
in the left calf which had changed from previous baseline as
she had not had pain DISEASE in the leg before No f/c. No n/v/d. No
CP/SOB. The blisters DISEASE on her legs occasionally drain non
purulent fluid but she reports no increased drainage over the
past few days. Was given a dose of vancomycin at HD.
.
In the ED initial VS were: 8 98 64 131/113 16 99%. Patient was
not given any additional antibiotics given recent dose at HD.
Underwent LLE ultrasound which showed no evidence of DVT DISEASE but
substantial subcutaneous edema DISEASE . Patient was to be admitted to
floor but repeat vitals showed BP of 80/50. Patient was
asymptomatic at that time without CP/SOB lightheadedness or
visual changes. Was given a 500cc bolus and responded to 89/50.
Subsequently admitted to MICU for further monitoring of vital
signs.
.
On arrival to the MICU patient is alert and oriented in NAD.
Notes minimal pain DISEASE and swelling DISEASE in the left calf. Denies f/c.
Denies CP/SOB. Of note she reports multiple week history of
cough DISEASE for which she was started on doxycycline by her PCP [**Last Name (NamePattern4) **]
[**4-10**]. Otherwise has no other complaints.


Past Medical History:
- Hypertension DISEASE
- Hyperlpidemia
- Ventricular tachycardia DISEASE s/p ICD implantation [**2193-4-1**] ([**Company 2275**] Cognis 100-D Dual chamber-ICD)
- Heart failure DISEASE systolic and diastolic EF 35%
- Atrial fibrillation DISEASE on warfarin
- Coronary artery disease
- COPD DISEASE
- Psoriasis DISEASE
- Gout DISEASE
- Allergic rhinitis DISEASE
- Hypokalemia DISEASE (in past)
- Anemia DISEASE normocytic
- ESRD DISEASE
- Obesity
- Cataract DISEASE
- Colon polyps
- Diverticulosis of colon with hemorrhage DISEASE

Social History:
-Former tobacco [**12-1**] pack per day x 25 years
-Previous alcohol use: quit 2 years ago
-Denies recreational drug use or other toxic habits
-Lives alone. Is able to complete her ADLs.

Family History:
[**Name (NI) 2280**] mother with 'heart trouble'

Physical Exam:
Vitals: T: 97.6 BP: 91/57 P: 65 R: 26 O2: 98%
General: Alert oriented no acute distress
HEENT: MMM oropharynx clear EOMI PERRL
Neck: supple JVP not elevated no LAD
CV: Regular rate and rhythm normal S1 Admission Date: [**2154-12-14**] Death DISEASE Date: [**2154-12-15**]


Service: MEDICINE/[**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
male with a history of encephalitis oral cancer DISEASE presenting
to Intensive Care Unit with shortness of breath DISEASE and hypoxia DISEASE
secondary to a large pleural effusion DISEASE . While in the
Intensive Care Unit the patient had transient hypotension DISEASE
and had a large O2 requirement secondary to the large effusion
and multiple pulmonary nodules almost certainly representing
metastatic disease. The patient was stabilized with IVF and
supplemental O2. The medical situation including presumed
widely metastatic cancer DISEASE with likely malignant effusion DISEASE was
discussed with the patient. Mr. [**Known lastname 1182**] firmly delined further
diagnostic interventions or therapies to work up and treat this.
Based on his firmly expressed opinion his code status
was made DNR/DNI and primary driver changed to maintaining
comfort.

On [**2154-12-15**] the patient was stable for transfer to floor for
further care. He remained with a high supplemental FiO2
requirement in order to maintain borderline sats. Mr. [**Known lastname 1182**]
frequently removed his face mask saying that he just wanted to
be comfortable. He expressed understanding that going without
supplemental Oxygen would put him at risk for respiratory or
cardiac arrest DISEASE .

On [**2154-12-15**] at 11:05 pm the senior resident was called to
see patient for unresponsiveness. The patient had continued
to refuse oxygen during the day into the evening. He had only
intermittently complied with wearing the mask secondary to
comfort concerns. as he had done in the MICU and earlin the
On evaluation by the sernior resident the patient had no
respirations. The patient had no response to voice or
sternal rub or other painful stimuli. The patient had no
heart sounds. Pupils were fixed and dilated. The patient was
pronounced dead. The Attending was notified and family
contact[**Name (NI) **].
DR.[**Last Name (STitle) **][**First Name3 (LF) **] 12-948



Dictated By:[**Last Name (NamePattern1) 1183**]

MEDQUIST36

D: [**2155-2-12**] 10:54
T: [**2155-2-12**] 11:12
JOB#: [**Job Number 1184**]





Admission Date: [**2136-12-19**] Discharge Date: [**2136-12-23**]

Date of Birth: [**2058-12-17**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Confusion lethargy DISEASE and hyperglycemia DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
78F h/o Atrial fibrillation DISEASE (not on coumadin) dementia DISEASE and DM2 DISEASE
sent in from rehab for altered MS today. She is demented at
baseline AAOx person and place and able to report immediate
medical complaints. She is a poor historian and oriented only
to self. She is stating only that she does not feel well.
Denies specific complaints when asked including chest pain DISEASE
SOB cough abdominal pain N/V diarrhea DISEASE and dysuria DISEASE . Did not
answer question about sick contacts. Daughter thinks she may
not have been eating quite as well as usual but otherwise has
been in her usual state of health without any complaints.
.
In the ED initial vitals 97.8 91 100/60 16 98% RA DISEASE . Labs
significant for glucose 1053 Hct 54 AG 25 Creatinine 1.7
lactate 8.1 K 4.0 Na 141 trop Admission Date: [**2184-10-10**] Discharge Date: [**2184-10-16**]

Date of Birth: [**2134-3-31**] Sex: M

Service: MED

Allergies DISEASE :
Penicillins / Nsaids / Ciprofloxacin

Attending:[**First Name3 (LF) 1190**]
Chief Complaint:
Rash DISEASE

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
50 yo male with PMH significant for EtOH abuse as well as
several psychological diagnoses presents to ER for evaluation
of rash DISEASE on his chest and legs/groin 1 week after starting
ciproflox for R hand cellulitis DISEASE . Rash DISEASE is pruritic DISEASE . No associated
fever DISEASE no respiratory compromise. In ER noted to be quite
tremulous DISEASE . Stated last drink was within 24h has a history of
Admission Date: [**2158-9-14**] Discharge Date:

Date of Birth: [**2115-11-19**] Sex: M

Service: [**Company 191**] MED

HISTORY OF PRESENT ILLNESS: This is a 42 year old Caucasian
male with a history of [**Location (un) 849**]-Gastaut syndrome refractory
epilepsy mental retardation DISEASE and frequent urinary tract
infections DISEASE who now presents with a two day history of
increased seizure DISEASE activity increased lethargy DISEASE and decreased
p.o. intake. This history is obtained from the patient's
caregiver. [**Name (NI) **] himself is nonverbal. Apparently patient
has an average of six seizures DISEASE per month tonic clonic DISEASE in
nature and associated with a 30 minute post ictal state. In
the past two days he has had a total of six seizures DISEASE already.
He is refusing all p.o. intake including his medications for
the past two days. The caregiver reports that his seizures DISEASE
usually increase in frequency when there is an associated
infection DISEASE . He did have one episode of nausea DISEASE with
questionable coffee ground emesis DISEASE one day prior to admission.
He was sent home from [**Hospital3 1196**] emergency
department after negative lavage and hematocrit of 40 one day
prior to admission. There is no evidence of sick contacts
fever DISEASE at home chills cough shortness DISEASE of breath chest
pain pain DISEASE anywhere foul smelling urine urinary DISEASE frequency
head injury rhinorrhea photophobia DISEASE .

PAST MEDICAL HISTORY: [**Location (un) 849**]-Gastaut syndrome diagnosed at
age 10 associated with approximately six seizures DISEASE a month.
Refractory epilepsy DISEASE . Partial synostosis of the left lambdoid
suture with compression of the left occipital lobe DISEASE and
posterior parietal lobe. Gastroesophageal reflux disease DISEASE .
Mental retardation. Recurrent urinary tract infections DISEASE .
Sinusitis DISEASE . Microcephaly.

MEDICATIONS ON ADMISSION: Colace 100 b.i.d. Protonix 40
q.d. Trileptal 600 t.i.d. Zoloft 100 q.d. Tums 1500 q.d.
multivitamin Felbatol 800 b.i.d. Miacalcin nasal spray.

ALLERGIES: Depakote ( rash DISEASE ) Neurontin ( rash DISEASE ) phenobarbital
Zarontin.

FAMILY HISTORY: Unknown. The caregiver does state that
patient's mother lives in the [**Name (NI) 86**] area.

SOCIAL HISTORY: The patient lives in a group home since [**2137**]
with five other mentally disabled people. He requires
constant supervision. He is nonverbal at baseline but is
able to communicate his needs per caregiver. There is no
history of tobacco alcohol or recreational drug use.

PHYSICAL EXAMINATION: Temperature 100.3 blood pressure
130/42 pulse 100 respirations 20 sating 86% in room air.
In general this was a pale cachectic DISEASE Caucasian male who
appeared younger than his stated age. He was awake did not
make any eye contact and was extremely agitated and restless DISEASE
requiring soft restraints. Pupils were equally round and
reactive to light. Nares were patent. Oropharynx was clear
but with poor dentition. Mucous membranes were moist. Neck
was supple without lymphadenopathy DISEASE JVD or carotid bruits DISEASE .
Lungs revealed coarse breath sounds anteriorly bilaterally.
Cardiac exam revealed that he was slightly tachycardiac S1
S2 normal without appreciable murmurs gallops or rubs.
Abdomen was soft nondistended nontender with normal bowel
sounds and no masses. Extremities displayed multiple areas
of ecchymosis DISEASE on his left lower extremity but were otherwise
unremarkable without evidence of edema erythema DISEASE or unusual
rashes. Neurologically patient moved all four extremities
spontaneously. He was nonverbal and did not follow commands.
There were no deep tendon reflexes elicited. Toes were
upgoing bilaterally but there were no signs of clonus.

LABORATORY DATA: Labs on admission notable for white count
of 18.7 with diff of 90 neutrophils 1 band 3 lymphocytes 6
monos. Hematocrit was 39 MCV 91. Sodium was 130 BUN 19
creatinine 0.7. UA demonstrated specific gravity of 1.020
with pH of 8 and all else negative. Chest x-ray on admission
was within normal limits and negative for any signs of
pneumonia DISEASE .

HOSPITAL COURSE: Given the patient's leukocytosis DISEASE and low
grade temperature both blood and urine cultures were drawn.
These continued to remain negative throughout his hospital
stay. Repeat chest x-ray was performed on hospital day one
and demonstrated left lower lobe atelectasis versus
infiltrate. Patient was thus started on empiric IV Levaquin
on hospital day one. He was aggressively hydrated with IV
fluids initially with normal saline secondary to sodium of
130. When his sodium normalized he was switched to
maintenance IV fluids. He was placed on both aspiration and
fall precautions and supervised by a one-to-one sitter at all
times. Given his questionable history of upper GI bleed one
day prior to admission hematocrit was followed closely and
remained stable throughout his hospital stay. He was
continued on daily Protonix and his stools were guaiac'd all
of which remained negative.

Regarding his seizure disorder DISEASE patient was continued on his
outpatient antiepileptics including Trileptal and Felbatol.
Since our pharmacy did not carry Felbatol he was allowed to
take his medications from home. He was placed in soft
restraints for his own safety during his seizure DISEASE episodes.
His outpatient neurologist Dr. [**Last Name (STitle) 851**] was informed
of the patient's in-house status. He was also given 0.5 mg
of p.r. or IV Ativan for prolonged seizures DISEASE . As his
infection DISEASE and dehydration DISEASE were both treated patient's
seizures DISEASE decreased in frequency and he soon returned to his
baseline status.

DISCHARGE DIAGNOSES:
1. Pneumonia aspiration versus community acquired.
2. Dehydration.
3. Refractory epilepsy DISEASE secondary to [**Location (un) 849**]-Gastaut syndrome.
4. Hypokalemia DISEASE .
5. Hypomagnesemia DISEASE .

DISCHARGE MEDICATIONS:
1. Colace 100 b.i.d.
2. Protonix 40 q.d.
3. Trileptal 600 t.i.d.
4. Zoloft 100 q.d.
5. Multivitamin.
6. Felbatol 800 b.i.d.
7. Miacalcin nasal spray.
8. Levaquin 500 q.d. for a total of a seven day course.

DISCHARGE STATUS: The patient was discharged back to his
group home from where he came in good condition. He is to
continue all his preadmission medications including a seven
day course of p.o. Levaquin for his presumed pneumonia DISEASE . He
is to follow up with his outpatient neurologist within the
next two weeks.






[**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 1197**]

Dictated By:[**Last Name (NamePattern4) 1198**]
MEDQUIST36

D: [**2158-9-15**] 19:50
T: [**2158-9-15**] 20:20
JOB#: [**Job Number 1199**]
Admission Date: [**2158-9-14**] Discharge Date: [**2158-9-21**]

Date of Birth: [**2115-11-19**] Sex: M

Service: [**Company 191**] Medicine

Stat addendum:

Unfortunately the patient was not discharged on [**9-16**]
as expected. On the morning of [**9-17**] he went into
status epilepticus DISEASE secondary to missing his scheduled doses
of his oral anti-epileptics. He was immediately intubated
for adequate airway protection and transferred to the
Intensive Care Unit for a brief stay. In the Intensive Care
Unit he was started on an Ativan drip to break his seizures DISEASE
and was loaded with Dilantin. His antibiotics were also
changed to intravenous clindamycin and ceftriaxone for a
presumed aspiration pneumonia DISEASE . A head CT was obtained which
was negative for any hemorrhage DISEASE or acute changes from his
prior study.

The patient was extubated without any complications after a
24 hour stay in the Intensive Care Unit. The EEG was
obtained prior to extubation which confirmed severe
encephalopathy DISEASE but no further seizure DISEASE activity. The patient
was then transferred to the floor on [**9-18**] in stable
condition. His Ativan drip his OT tube and his central line
were all discontinued. His IV Dilantin was then changed to
po Dilantin and was increased by the neurology service.
Daily Dilantin levels were checked. He continued to remain
afebrile with all vitals stable throughout the rest of his
hospital stay. He remained seizure DISEASE free and was able to
tolerate po's (both medications and food) without any
trouble. His intravenous antibiotics were changed to a po
regimen on the day of discharge.

DISCHARGE STATUS: He will be discharged back to his group
home on [**9-18**] in good condition. He is to resume all
pre admission medications with the addition of po Dilantin
125 mg in the morning 100 at noon and 100 at night. He is
also to complete a seven day course of po Levaquin. He is to
follow up with Dr. [**Last Name (STitle) 851**] his neurologist within the
next two weeks.




[**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 1197**]

Dictated By:[**Last Name (NamePattern4) 1198**]
MEDQUIST36

D: [**2158-9-21**] 10:23
T: [**2158-9-21**] 10:46
JOB#: [**Job Number 1200**]
Admission Date: [**2164-5-4**] Discharge Date: [**2164-5-18**]

Date of Birth: [**2115-11-19**] Sex: M

Service: SURGERY

Allergies DISEASE :
Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /
Tranxene Sd

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain DISEASE

Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Exploration of retroperitoneum.
3. Open cholecystectomy.
4. Venting decompressed colotomy.
5. J-tube placement.


History of Present Illness:
This 48-year-old [**First Name3 (LF) 1229**] has mental retardation and a seizure DISEASE
syndrome. He presents to our emergency room acutely with reports
of [**1-15**] days of abdominal
pain DISEASE as described by his caretakers who find him grimacing DISEASE in
an umbilical position. He had a change in bowel habits and
decreased PO intake for 2 weeks. He is largely unresponsive and
he responds only to keep the stimulation for pain DISEASE . He has had
fevers DISEASE for the last few days up as high as 104 degrees. A
workup was performed for this and initial imaging of the
abdomen showed multiple views consistent with a free air in the
abdomen. This with a lactic acidosis DISEASE distended abdomen and a
neutrophilia DISEASE band shift along with the after mentioned history
was very concerning for an acute process which
required an emergent operation. This was especially so given the
fact that we could not adequately communicate with this
[**Name2 (NI) 1229**] and did not know the full extent of his recognition of
pain DISEASE due to his mental retardation.


Past Medical History:
[**Location (un) 849**] Gastaut DISEASE Syndrome neurologist Dr. [**Last Name (STitle) 851**]
Seizure disorder DISEASE
Mental retardation
Osteoporosis DISEASE
Peripheral neuropathy DISEASE secondary to dilantin
h/o hyponatremia DISEASE secondary to trileptal
GERD
Behavioral d/o


Social History:
Lives in group home. Non-verbal at baseline. Does not smoke or
drink EtOH
.

Patient lives in a group home. # [**Telephone/Fax (1) 852**]. Has a legal
guardian Rev [**First Name8 (NamePattern2) **] [**Name (NI) 853**] c # [**Telephone/Fax (1) 854**] w # [**Telephone/Fax (1) 855**].



Family History:
Noncontributory

Physical Exam:
104 100 94/37
Gen: non responsive NAD no jaundice DISEASE
CV: S1 S2 no MRG
Chest: CTA bilat decreased at right base
Abd: soft nondistended no rebound or guarding.

Pertinent Results:
[**2164-5-4**] 07:05PM BLOOD WBC-10.0# RBC-4.49* Hgb-12.9* Hct-39.8*
MCV-89 MCH-28.8 MCHC-32.5 RDW-16.9* Plt Ct-296
[**2164-5-8**] 01:58AM BLOOD WBC-14.2* RBC-3.29* Hgb-9.7* Hct-29.3*
MCV-89 MCH-29.5 MCHC-33.1 RDW-17.0* Plt Ct-232
[**2164-5-8**] 09:40AM BLOOD Glucose-114* UreaN-8 Creat-0.5 Na-131*
K-3.6 Cl-95* HCO3-25 AnGap-15
[**2164-5-6**] 02:08AM BLOOD ALT-83* AST-125* LD(LDH)-222 AlkPhos-62
Amylase-19 TotBili-0.3
[**2164-5-8**] 09:40AM BLOOD Calcium-7.3* Phos-3.3# Mg-1.4*
[**2164-5-4**] 11:57PM BLOOD Triglyc-78
[**2164-5-8**] 01:58AM BLOOD Phenyto-17.1
.
CHEST (PORTABLE AP) [**2164-5-4**] 7:25 PM
PORTABLE UPRIGHT CHEST ONE VIEW: Heart size is normal. There is
a mild hilar prominence with patchy areas of airspace opacities DISEASE
bilaterally. Given the history of prolonged seizure DISEASE these may
represent areas of aspiration. There is no pneumothorax DISEASE . There
is no pleural effusion DISEASE .
There is a massive amount of free intraperitoneal air with free
air seen underneath both hemidiaphragms. Osseous structures are
unremarkable.
IMPRESSION:
1. Massive amount of pneumoperitoneum.
2. Multifocal patchy areas of airspace opacity DISEASE likely
represents aspiration and possible superimposed neurogenic
pulmonary edema DISEASE .
.
CHEST (PORTABLE AP) [**2164-5-5**] 4:07 PM
Comparison is made with prior study performed the same day
earlier in the morning.
Cardiomediastinal contour is unchanged. Diffuse airspace
opacities DISEASE worse on the right side are unchanged. There are no
new lung abnormalities DISEASE . As mentioned before these are
suspicious for aspiration. There are no increasing pleural
effusions.
.
CHEST (PORTABLE AP) [**2164-5-8**] 8:07 AM
FINDINGS: In comparison with the study of [**5-5**] there has been
some decrease in the still substantial bilateral pulmonary
opacifications suspicious for aspiration.
.
CHEST (PORTABLE AP) [**2164-5-9**] 1:14 AM

CHEST (PORTABLE AP)

Reason: new NGT

[**Hospital 93**] MEDICAL CONDITION:
48 year old man s/p ccy
REASON FOR THIS EXAMINATION:
new NGT
HISTORY: New nasogastric tube.

FINDINGS: In comparison with the study of [**5-8**] there has been
placement of a nasogastric tube that coils within the fundus of
the stomach. The diffuse bilateral pulmonary opacification DISEASE shows
a slow steady decrease.
.
[**2164-5-15**] 06:00AM BLOOD WBC-13.1* RBC-3.44* Hgb-10.3* Hct-31.3*
MCV-91 MCH-29.9 MCHC-32.9 RDW-18.3* Plt Ct-940*
[**2164-5-18**] 09:25AM BLOOD WBC-16.0* RBC-2.91* Hgb-8.7* Hct-26.9*
MCV-93 MCH-29.8 MCHC-32.2 RDW-18.7* Plt Ct-960*
[**2164-5-14**] 05:55AM BLOOD Glucose-86 UreaN-6 Creat-0.5 Na-132*
K-4.0 Cl-101 HCO3-22 AnGap-13
[**2164-5-6**] 02:08AM BLOOD ALT-83* AST-125* LD(LDH)-222 AlkPhos-62
Amylase-19 TotBili-0.3
[**2164-5-18**] 09:25AM BLOOD Albumin-2.5*
[**2164-5-14**] 05:55AM BLOOD Calcium-7.4* Phos-3.1 Mg-2.1
[**2164-5-16**] 06:05AM BLOOD Vanco-20.5*
[**2164-5-13**] 12:25PM BLOOD Vanco-11.9
[**2164-5-18**] 04:54AM BLOOD Phenyto-7.2*
[**2164-5-16**] 06:10AM BLOOD Phenyto-13.7
[**2164-5-15**] 06:00AM BLOOD Phenyto-8.5*
[**2164-5-14**] 05:55AM BLOOD Phenyto-5.4*
[**2164-5-12**] 06:05AM BLOOD Phenyto-10.4
.
ECHO
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness cavity size and regional/global systolic function are
normal (LVEF Admission Date: [**2194-2-16**] Discharge Date: [**2194-2-19**]

Date of Birth: [**2130-11-19**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1242**]
Chief Complaint:
Hyperglycemia DISEASE unsteady gait

Major Surgical or Invasive Procedure:
None

History of Present Illness:
63 yof with history of of DM Type I CAD s/p MI s/p CABG HTN DISEASE
Hyperlipidemia PVD DISEASE s/p left popliteal bypass who presents with
hyperglycemia DISEASE . Pt was recently discharged after admission for
hyperglycemia DISEASE and TIA DISEASE . Patient states she was home and not
feeling herself. Admission Date: [**2166-3-17**] Discharge Date: [**2166-3-24**]

Date of Birth: [**2126-8-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Kefzol / Ibuprofen / Ketoconazole / Adhesive Tape
/ Shellfish Derived

Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
etoH withdrawal

Major Surgical or Invasive Procedure:
R femoral line


History of Present Illness:
Pt is a 39 yo M c h/o EtOH abuse recurrent abdominal pain DISEASE
gastritis DISEASE Admission Date: [**2168-5-6**] Discharge Date: [**2168-5-11**]

Date of Birth: [**2126-8-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Kefzol / Ibuprofen / Ketoconazole / adhesive tape
/ Shellfish Derived

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
EtOH withdrawal sxs

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
41 y.o. Male with current EtoH abuse h.o. DTs seizures DISEASE
presents EtoH withdrawal symptoms.
.
Pt states he usually drinks at least a 12 pack a day
unfortunately he could not afford any more alcohol so he started
to withdraw. His last drink was yesterday at 5pm. He noted some
sweats diarrhea chills DISEASE and a headache DISEASE along with tremors DISEASE which
he usually experiences when he withdraws. He also noted some
epigastric pain DISEASE with radiation to the back after he stopped
drinking he started to eat something this morning and threw it
up. He threw it up because of his abdominal pain DISEASE and nausea DISEASE . He
said the 3 rd time he threw up he noted some blood which
increased in concentration the more he threw up. He decided to
come into the ED for his withdrawal and pain DISEASE issues.
.
In the ED initial VS were noted to be T98.8 HR 116 BP 199/108
RR 18 Sat 100% on RA DISEASE . Her initial labwork was notable for a
negative serum tox screen including EtoH. He was noted to have
tongue fasiculations tremors DISEASE and was given initially Diazepam
10mg IV x 1 10mg PO x 1. He was also noted to have nausea DISEASE
vomiting epigastric pain DISEASE . He was started on D5W gtt. Chem panel
showed an AG of 19 but HCO3 of only 23. Lactate 0.7. She was
given Thiamine 100mg PO x 1 Folic Acid 1mg PO x 1 Zofran for
nausea DISEASE . Per ED signout pt had ketones in urine though it is
unclear as to where the urine findings were noted. He received
1L NS and was started on D5NS maintenance fluid and received
approx 100cc DISEASE . Pt was also guaiac negative in the ED.
.
On the floor pt stated he still had some abdominal pain DISEASE and
still felt as if he was withdrawing. He does not have any emesis DISEASE
currently his last episode was several hours ago in the ED. He
is usually seen at [**Hospital 882**] hospital and was recently there 2
months ago and hospitalized for a month for Admission Date: [**2164-9-6**] Discharge Date: [**2164-9-12**]

Date of Birth: [**2093-1-13**] Sex: F

Service: MED

Allergies DISEASE :
Blood Adminstration Equipment

Attending:[**First Name3 (LF) 338**]
Chief Complaint:
DOE and CP

Major Surgical or Invasive Procedure:
None

History of Present Illness:
71F with DM HTN Hyperlipidemia who was well until [**9-7**] when
she noticed LLE swelling. She soon experienced acute onset of
sharp SSCP along with SOB and DOE. At baseline the patient runs
her own day care and is fairly active picking up and chasing
after children. She can climb up to nine flights of stairs
without chest pain DISEASE or chest pain DISEASE . She has had no miscarriages or
h/o difficulty conceiving. There is no h/o PE or DVT DISEASE . Pt takes
no estrogens herbals OTCs and does not use drugs or
cigarettes. No recent foreign travel or sick contacts.

Found to have large b/l PEs - hemodyn stable since admission.
On heparin o/n but access issue. Now on lovenox. Coumadin
started on admission.

ROS: No abd pain bloating F/C weight changes rash bruising DISEASE .
Pt has baseline lumbar pain DISEASE worse with walking. She also has
had upper back pain DISEASE which began after her meningioma DISEASE removal 1
yr PTA.

Past Medical History:
HTN DISEASE DMII ( Diet-controlled DISEASE ) Hyperlipidemia DISEASE S/P Spinal
Meningioma DISEASE Resection and T4-T6 DISEASE Laminectomy/Fusion S/P CCY
Cataracts DISEASE S/P Hysterectomy


Social History:
Lives at home with her daughter and grandaughter. Has four
children. Runs day care out of her houseAdmission Date: [**2130-2-3**] Discharge Date: [**2130-2-9**]

Date of Birth: [**2060-12-25**] Sex: M

Service: SURGERY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Bright red blood per rectum

Major Surgical or Invasive Procedure:
None


History of Present Illness:
69 yo M presents 8 days s/p anal seton placement with a 24 hour
history of bright red blood per rectum soaking his clothes. He
turned the toilet water dark red approximately 15 times.
Multiple large clots seen. He complains of associated dizziness DISEASE
and had hypotension DISEASE in the ED. Denies fevers chills N/V DISEASE or
change in appetite.

Past Medical History:
1. Crohn's DISEASE dz found in [**2125**] on colonoscopy for anal fissure DISEASE
positive [**Doctor First Name **] been treated with Remicade
2. Rheumatoid arthritis DISEASE
3. HTN DISEASE
4. hx of renal calculus
5. s/p appendectomy
6. s/p TURP
7. s/p cholecystectomy
8. Recent pulmonary embolism- on coumadin since [**2-12**]
9. LVH LV enlargement apical LV aneurysm DISEASE with LV thrombus DISEASE EF
25%
10. Chronic left knee pain DISEASE s/p meniscectomy synovectomy and
debridement of left knee [**2123**]
11. Recent gallstone pancreatitis DISEASE [**2-12**]
12. Afib DISEASE - [**2-12**] rate controlled on atenolol


Social History:
Married for 46 years and lives with wife. 3 children who all
live in area. No tobocco h/o occasional ETOH stopped drinking
in [**11-13**] denies h/o ETOH abuse. No illicit drugs.


Family History:
Father died at 62 from MI
Mother died at 52 of cirrhosis DISEASE
No cancer DISEASE or diabetes DISEASE to patient's knowledge
No hisotry of clotting disorders DISEASE

Physical Exam:
At time of discharge:

A&O X 3 NAD
RRR
CTAB
Abd soft NT/ND DISEASE Admission Date: [**2128-1-11**] Discharge Date: [**2128-1-21**]

Date of Birth: [**2057-1-13**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain DISEASE

Major Surgical or Invasive Procedure:
[**2128-1-11**] - Cardiac Catheterization
[**2128-1-15**] CABGx4 (LIMA-Admission Date: [**2113-4-28**] Discharge Date: [**2113-5-3**]

Date of Birth: [**2040-12-26**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Sycope fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 72 year old female on aspirin who fell [**2113-4-28**]
at home. She states that she felt lightheaded and then next
remembers being on the tiled floor in the kitchen. The fall was
unwitnessed DISEASE with reported loss of consciousness DISEASE and the patient
does not know how long she was down for. She reports 4 episodes
of vomiting DISEASE since her fall. She complains of numbness DISEASE and
tingling sensation in her hands weakness DISEASE in her hands and legs.
She denies bowel or urine incontinence hearing or visual DISEASE
deficit.She denies use of assistive devices to ambulate at home.
She reports 4 episodes of lightheadedness DISEASE in the past.


Past Medical History:
CVA DISEASE [**2105**]

Social History:
The patient lives at home with her husband

Physical Exam:
On admission:
PHYSICAL EXAM DISEASE :
O: T:96.5 BP: 100/50 HR:54 R: 16 O2Sats: 100%
Gen: comfortable NAD.
HEENT: 2 cm occipital lac Pupils: 2.5-2mm EOMs: intact
Neck: hard cervical collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert cooperative with exam normal
affect.
Orientation: Oriented to person place and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria DISEASE .

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light 2.5 to 2
mm bilaterally. Visual fields are full to confrontation.
III IV VI: Extraocular movements DISEASE intact bilaterally without
nystagmus DISEASE .
V VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX X: Palatal elevation DISEASE symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius DISEASE normal bilaterally.
XII: Tongue midline without fasciculations DISEASE .

Motor: Normal bulk and tone bilaterally. No abnormal movements DISEASE
tremors DISEASE .
Strength Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 4 4 3 3 4 2 2 2
L 5 5 5 4 3 3 3 5 4Admission Date: [**2113-5-3**] Discharge Date: [**2113-5-25**]

Date of Birth: [**2040-12-26**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Admission Date: [**2152-3-23**] Discharge Date: [**2152-3-31**]

Date of Birth: [**2072-12-24**] Sex: M

Service: CSU


HISTORY OF PRESENT ILLNESS: This is a 79-year-old gentleman
with a longstanding history of coronary artery disease DISEASE . He
had an initial percutaneous transluminal coronary angioplasty
of his left circumflex in [**2137**]. In [**2139**] he had a
catheterization that showed 100 percent right coronary artery
occlusion and a subtotal circumflex lesion with a
percutaneous transluminal coronary angioplasty done. At the
same time he had a mild left anterior descending occlusion
with some venous obstruction DISEASE .

Over the past few months he has had increasing angina with
exertion. On [**2152-1-11**] he had an exercise tolerance
test that was positive with ST depressions with
inferoposterior ischemia DISEASE . His angina is primarily between
his scapula and back. He was referred for cardiac
catheterization which was done on [**2152-1-28**]. This
revealed an ejection fraction of 60 percent. He had a mildly
dilated aortic root right-dominant system left main with a
20 percent occlusion diagonal with 70 percent ramus with 80
percent circumflex with 95 percent left anterior descending
with 70 percent with distal left anterior descending 90
percent occlusion obtuse marginal with 80 occlusion right
coronary artery with 100 percent and posterior descending
artery with 70 percent. No mitral regurgitation DISEASE or aortic
stenosis. At that time he was referred for bypass surgery.

PAST MEDICAL HISTORY:
1. Glaucoma DISEASE .
2. Tuberculosis DISEASE .
3. Ventral hernia DISEASE .
4. Question of lumbar stenosis DISEASE .
5. Coronary artery disease DISEASE (with percutaneous transluminal
coronary angioplasty in [**2137**] and [**2139**]).
6. Left-sided headaches DISEASE (with question of temporal
arteritis DISEASE ).
7. Left carotid disease DISEASE .
8. Diverticulitis DISEASE .
9. Hypertension DISEASE .
10. Hiatal hernia DISEASE with gastroesophageal reflux disease DISEASE .
11. Elevated cholesterol.
12. Benign prostatic hypertrophy DISEASE .


PAST SURGICAL HISTORY:
1. Tonsillectomy and adenoidectomy (as a child).
2. Colon polypectomy.
3. Bilateral laser eye surgery.


ALLERGIES: SULFA (causes hot flashes).

PHYSICAL EXAMINATION ON PRESENTATION: The patient's height
was 5 feet 9 inches tall his weight was approximately 175
pounds blood pressure in the left arm was 180/66 and his
right arm blood pressure was 188/80. Cardiovascular
examination revealed a rate and rhythm. Normal first heart
sounds and second heart sounds. There was a 2/6 systolic
ejection murmur. The lungs were clear to auscultation
bilaterally. The abdomen was soft nontender and
nondistended. Left upper quadrant diverticula and ventral
hernia DISEASE . Extremities were warm and well perfused. There were
no varicosities. Good circulation sensation mobility.
Pulse examination revealed right and left femoral were 2
plus right and left dorsalis pedis pulses were 2 plus right
and left posterior tibialis were 2 plus and right and left
radial pulses were 2 plus. Neurologically the pupils were
equal round and reactive to light and accommodation.
Cranial nerves II DISEASE through XII were grossly intact. A
nonfocal examination. Head eyes ears nose DISEASE and throat
examination revealed the extraocular movements DISEASE were intact.
The sclerae were anicteric and not injected. There were
buccal mucosa. Neck examination revealed there was no
jugular venous distention DISEASE . There were no bruits DISEASE .

PERTINENT LABORATORY VALUES ON THE DAY OF DISCHARGE: White
blood cell count was 10.2 his hematocrit was 32.9 and his
platelets were 349. Potassium was 4.7 his blood urea
nitrogen was 16 and his creatinine was 0.8.

PERTINENT RADIOLOGY/IMAGING: Last chest x-ray revealed a
small bilateral effusion. No congestive heart failure DISEASE . No
pneumothorax DISEASE .

BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
on [**3-23**] and underwent a coronary artery bypass graft times
three. He was extubated that afternoon. He was initially A-
paced at 80 with an underlying sinus bradycardia DISEASE at a rate of
50.

On postoperative day three he went into atrial flutter DISEASE .
After 5 mg of intravenous Lopressor he had a nine second
pause with conversion to a sinus rhythm. That day he had
three subsequent pauses of about six seconds each and the
Electrophysiology Service was consulted. On [**3-26**] he had
some atrial fibrillation DISEASE and atrial flutter DISEASE with a rate in
the 80s to 90s.

On the evening of [**3-27**] he went into an accelerated
idioventricular rhythm and was subsequently A-paced at 80.
He continued in a normal sinus rhythm with some episodes of
accelerated idioventricular rhythm but he was asymptomatic.
On [**3-27**] the patient was started on 12.5 mg of by mouth
Lopressor (per Electrophysiology). They did not recommend a
pacemaker or defibrillator placement.

The patient was transferred to the inpatient floor on [**3-29**].
His chest tubes had been removed on [**3-26**] and his cardiac
pacing wires were removed on [**3-29**]. He had been followed
throughout his hospital course by the Physical Therapy
Service. His chest tubes had come out on the [**3-26**]. The
patient was cleared for home by the Physical Therapy Service
on [**3-30**].

CONDITION ON DISCHARGE: Vital signs revealed his pulse was
65 (in a sinus rhythm) his blood pressure was 138/64 his
respiratory rate was 18 and his oxygen saturation was 95
percent on room air. His temperature maximum was 99.3
degrees Fahrenheit. His weight on discharge was 79
kilograms. Preoperatively 79 kilograms as well. The patient
was alert awake and oriented times three. The sternal
incision was clean dry and intact with a stable sternum.
Bilateral lower extremity vein harvest sites were clean dry
and intact with moderate ecchymosis DISEASE on the right thigh.
Cardiovascular examination revealed a rate and rhythm.
Respiratory examination revealed the lungs sounds were clear.
There were scattered rhonchi on the right side.
Gastrointestinal examination revealed there were positive
bowel sounds. The abdomen was soft nontender and
nondistended. Extremity examination revealed some trace
lower extremity edema DISEASE .

DISCHARGE STATUS: The patient was discharged to home with
Visiting Nurses Association on [**3-30**] in stable condition.

DISCHARGE DIAGNOSES:
1. Coronary artery diseaseAdmission Date: [**2115-10-29**] Discharge Date: [**2115-11-16**]


Service: [**Hospital Unit Name 196**]

Allergies DISEASE :
Vitamin K / Niacin

Attending:[**Location (un) 1279**]
Chief Complaint:
Coronary Artery Disease DISEASE

Major Surgical or Invasive Procedure:
Left CCA DISEASE puncture
Intubation


History of Present Illness:
81 y/o M with critical AS and 3VD who presents for CHF DISEASE
exacerbation. Pt transferred from [**Hospital3 1280**] after ruling in
for AMI and was awaiting CABG/AVR DISEASE . Pre-operative course
complicated by MRSA UTI and L SCV thrombosis DISEASE . Pt noted to have
incidental L CCA DISEASE puncture during IJ central venous access
attempt. This was likely due to a goiter DISEASE found later in the
hospital course.

Past Medical History:
DM
HTN DISEASE
Bladder CA


Pertinent Results:
[**2115-11-16**] 06:15AM BLOOD WBC-11.4* RBC-4.04* Hgb-13.0* Hct-37.7*
MCV-93 MCH-32.2* MCHC-34.5 RDW-12.7 Plt Ct-354
[**2115-11-15**] 05:54AM BLOOD Neuts-88.9* Lymphs-6.3* Monos-4.6 Eos-0.1
Baso-0
[**2115-11-16**] 06:15AM BLOOD Plt Ct-354
[**2115-11-15**] 05:54AM BLOOD PT-13.4 PTT-24.3 INR(PT)-1.1
[**2115-11-16**] 06:15AM BLOOD Glucose-84 UreaN-54* Creat-1.1 Na-140
K-4.2 Cl-99 HCO3-29 AnGap-16
[**2115-11-12**] 06:05AM BLOOD ALT-62* AST-73* LD(LDH)-246 AlkPhos-106
TotBili-0.8 DISEASE
[**2115-11-7**] 07:21AM BLOOD CK(CPK)-132
[**2115-11-6**] 11:34PM BLOOD CK(CPK)-138
[**2115-11-7**] 07:21AM BLOOD CK-MB-6 cTropnT-0.17*
[**2115-11-16**] 06:15AM BLOOD Calcium-9.9 Mg-1.8
[**2115-11-15**] 05:54AM BLOOD Calcium-9.8 DISEASE Phos-4.3 Mg-1.9
[**2115-10-29**] 07:42PM BLOOD %HbA1c-5.3
[**2115-11-14**] 07:00AM BLOOD TSH-0.55
[**2115-11-14**] 07:00AM BLOOD Free T4-1.9*

Brief Hospital Course:
1. Cardiac: Pt with 3VD cath'd at [**Hospital3 1280**] that showed 80%
prox LAD 80% D2 80% prox LCx involving ostium and patent RCA
with stent. Mid PDA with 50% stenosis. Pt also with critical AS
with valve area 0.7cm squared with mean gradient 60mmHg. The
pt's pre-op course was complicated by MRSA UTI which was treated
with vanc without problem. The pt was found to have decreased
BP's in the LUE and hx LUE claudication subsequently found to
have L SCV stenosis DISEASE by arteriography which was not intervened
on. The pt went to the OR for CABG and AVR/MVR DISEASE [**2115-11-6**] when
his L common carotid artery was punctured during IJ venous
access attempt. The bleeding DISEASE was controlled with pressure and
the pt was intubated for airway control. During this process
the pt was administered fluid resuscitation and went into acute
pulmonary edema DISEASE . The CCU team was called took over the pt's
care. He was diuresed aggressively with IV lasix drip and
nitroglycerin drip for unloading. Pt extubated [**2115-11-7**] with [**Last Name **]
problem. CT surgery feels the patient should wait at least 8
weeks from time of discharge to CABG because of increased bleed DISEASE
risk from CCA DISEASE puncture.

2. Rhythm: The pt was noted to be in Mobitz I HB with
borderline prolonged PR and atrial ectopy DISEASE . He was evaluated by
the EP service who felt this problem should be addressed as an
outpt. He will have f/u for potential pacemaker device after
CABG.

3. UTI: The pt had a MRSA UTI while in house. He was
successfully treated with 7 day course of vancomycin. F/U UA's
have been negative for persistence of infection DISEASE .

4. CCA puncture: Occurred during IJ attempt in OR. Likely
occurred secondarily to large thyroid mass interfering with
great vessel anatomy (see below). Doppler son[**Name (NI) 867**] found a
fistula DISEASE between the L CCA DISEASE and IJV. Vascular surgery followed
the patient and did not feel the fistula DISEASE would require
intervention. Serial dopplers reveal a decrease in the size of
the fistula DISEASE encouraging for eventual spontaneous closure.
Mr.[**Known lastname **] did require one unit of PRBC for anemia DISEASE thought to be
secondary to this bleeding DISEASE .

5. Thyroid Mass: Found on chest CT. Thyroid ultrasound
revealed a 4X5cm posterior heterogenous thyroid mass that was
not biopsied based on pt's coughing during procedure. TSH 0.55
with free T41.9. Likely represents a multinodular DISEASE non-toxic
goiter DISEASE . Pt should be seen by an endocrinologist prior to CABG.


6. Elevated R Hemidiaphragm: Found on routine CXR.
Ultrasonographic sniff test revealed diminished (but present)
right diaphragmatic excursion. CT chest showed RLL collapse
with mucus plug in RLL bronchus. Aggressive chest PT initiated.
Insentive spirometry was already being used since admission.
Pt does follow a pulmonologist at [**Location (un) 47**] [**Hospital1 1281**] for this
problem which has been present for years.

7. Gout DISEASE : Pt noted to have erythematous swollen warm R-sided
hand and foot oligo-arthritis consistent with gouty DISEASE flare.
Rheumatology consulted suggested 3 week prednisone taper.

Discharge Medications:
1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO QD (once a
day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO QD (once a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
13. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Centrus Home Care

Discharge Diagnosis:
3VD with critical AS


Discharge Condition:
Good

Discharge Instructions:
Come to the ER if you have these symptoms:

1. chest pain DISEASE
2. shortness of breath
3. fluttering in your chest
4. fainting
5. darkening of your vision

Followup Instructions:
Please call Dr[**Doctor Last Name 1282**] office for an appointment.



Please call your primary care physician and schedule an
appointment (call [**11-18**]) for [**11-19**].




Completed by:[**2115-12-4**]Admission Date: [**2115-12-23**] Discharge Date: [**2116-1-25**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Vitamin K / Niacin

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
CAD 3 vessel CAD Aortic Stenosistoxic
multinodular goiter CHF DISEASE exacerbation


Major Surgical or Invasive Procedure:
Operative Note #[**Numeric Identifier 1284**] - CCC
Name: [**Known lastname **] [**Known firstname **] Unit No: [**Unit Number 1285**]

Service: CSU DISEASE Date: [**2115-12-25**]


Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1286**] MD 2178

FIRST ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] RES

PREOPERATIVE DIAGNOSIS: Toxic multi-nodular goiter DISEASE with left
major substernal component.

POSTOPERATIVE DIAGNOSIS: Toxic multi-nodular goiter DISEASE with
left major substernal component.

PROCEDURE PERFORMED: Left sternal thyroidectomy with sternal
split.
[**Known lastname **][**Known firstname **]: [**Hospital1 18**] Notes Detail - CCC Record #[**Numeric Identifier 1285**]
Operative Note #[**Numeric Identifier 1287**] - CCC
Name: [**Known lastname **] [**Known firstname **] Unit No: [**Unit Number 1285**]

Service: CSU DISEASE Date: [**2115-11-6**]


Surgeon: [**Doctor Last Name **] [**Last Name (Prefixes) **] M.D. [**MD Number(1) 1288**]

PREOPERATIVE DIAGNOSIS: Coronary artery disease DISEASE aortic
stenosis severe mitral regurgitation DISEASE moderate peripheral
vascular disease DISEASE hypertension DISEASE .

POSTOPERATIVE DIAGNOSIS: Coronary artery disease DISEASE aortic
stenosis severe mitral regurgitation DISEASE moderate peripheral
vascular disease DISEASE hypertension DISEASE .

OPERATION: Case planned for an aortic valve replacement
mitral valve replacement and coronary artery bypass graft
cancelled secondary to intraoperative carotid injury DISEASE during
left internal jugular vein Swan introducer placement by
anesthesia.

PROCEDURE: Mr. [**Known lastname **] was to undergo a possible multivalve
coronary artery bypass graft today. After anesthesia the
patient was having an left internal jugular vein Swan Ganz
introducer catheter placed using the Seldinger technique by
anesthesia. After confirmation of placing the wire into the
superior vena cava they were unable to pass the dilator.
Upon withdrawal of the dilator brisk red blood was coming
out the small skin incision that appeared to be pulsatile.
Immediately direct pressure was applied and an intraoperative
vascular surgery consult was obtained. It took approximately
25 to 30 minutes for pressure to achieve excellent
hemostasis.

Intraoperative Duplex ultrasound of the carotid showed
antegrade flow with a very small low flow left carotid to
left internal jugular vein fistula DISEASE . It was felt by the
vascular surgeon that this would probably thrombose on its
own and would be re-evaluated within the next day.

Given the nature of the injury and the patient being a
vasculopath we elected to obtain a neurology consult as well
as attempt to wake the patient up. After reversal of the
chemical paralysis DISEASE and sedation the patient did in fact move
all of his extremity to command and perform complex tasks.
The patient was therefore extubated and appeared to be
neurologically intact.

At[**Last Name (STitle) 1289**]time the case was cancelled and the patient will be
brought back to the intensive care unit for critical
monitoring of all organ systems. Dr. [**Last Name (Prefixes) **] was present
and participated throughout all significant portions of his
preoperative care.


[**2115-12-25**] Dr. [**Last Name (STitle) 1290**] [**Name (STitle) 1291**]/ CABG x 3

History of Present Illness:
81 yo male admitted [**2115-12-23**]
from OSH with recent CHF DISEASE exacerbation severe 3 VD severe AS
with CABG/MVR/[**Month/Day/Year 1291**] postponed due to carotid puncture and then
pre-op course c/b L SCV thrombosis DISEASE pulmonary edema DISEASE elevated R
hemidiaphragm due to RLL collapse & mucous plug and dx of toxic

multinodular goiter DISEASE . [**2115-12-28**] pt underwent CABG/[**Month/Day/Year 1291**] not MVR
and left thyroidectomy. [**12-30**]- pt was extubated but on [**1-2**] -
pt
was reintubated due to fatigue DISEASE . [**2116-1-7**]- pt was extubated.Pt has
been NPO since that time on NG tube feedings. getting excellent
physical therapy and progression from deabiliation related to
prolonged ICU stay

Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post RCA stent in [**2103**]
An exercise tolerance test/SPECT ([**6-1**]) demonstrated inferior
inferoseptal inferoapical defects without symptoms but
ischemic
electrocardiographic changes.
2. Moderate AS. Transthoracic echocardiogram done [**2112-5-31**]
showed
ejection fraction 60 percent left ventricular hypertrophy DISEASE
mild aortic insufficiency DISEASE moderate aortic stenosis DISEASE with [**Location (un) 109**]
0.98 cm sq peak gradient 50 mmHg mean gradient 27 mmHg.
3. Peripheral vascular disease DISEASE with lower extremity
claudication and status post CEA.
4. Bladder cancer DISEASE status post tumor DISEASE excision two years ago
biopsy last month. Patient unaware of results. No past
chemotherapy or radiation therapy.
5. Sciatica treated with Neurontin.
6. CHF DISEASE .
7. DM
8. 1rst degree AVB
9. Gout DISEASE

PAST SURGICAL HISTORY: Status post right carotid
endarterectomy five years ago status post right femoral
popliteal bypass five years ago.


Social History:


SHx: Quit smoking 10y ago after 20 years hx of heavy smoking.


Family History:
FHx: father CAD pt unsure of age.

Physical Exam:
Elderly male
VS: *100/70 L arm *168/82 R arm
HR 72 sat 100% RA DISEASE

neck: Admission Date: [**2130-12-15**] Discharge Date: [**2130-12-18**]

Date of Birth: [**2057-10-30**] Sex: M

Service:

DIAGNOSIS: Sepsis.

HOSPITAL COURSE: (Summary of the patient's medicine
Intensive Care Unit course from [**2130-12-15**] until
[**2130-12-18**])

HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
male with recently diagnosed nonHodgkin's lymphoma DISEASE in
[**2130-9-11**]. The patient presented with low back pain DISEASE
and was found to have a poor compression. The patient was
treated with radiation and steroids from [**Month (only) **] until
[**2130-10-18**] and then discharged to [**Hospital **]
Rehabilitation for rehabilitation. The patient was
readmitted on [**2130-11-8**] for Rituxan treatment per
oncology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. After receiving first dose of
Rituxan the patient had an adverse reaction including
hypotension tachycardia fever DISEASE and hypoglycemia DISEASE . The
hospital course was notable for syndrome of inappropriate
antidiuretic hormone change in mental status and anemia DISEASE .
The patient was then discharged to [**Hospital1 **] on [**2130-11-12**]. The patient now returns to the Emergency Room on the
day of admission with lethargy DISEASE and shortness of breath DISEASE . The
patient has been undergoing treatment with Levofloxacin for
presumed pneumonia DISEASE since [**12-11**]. At [**Hospital1 **] the patient
was short of breath and was given in addition to Levofloxacin
Vancomycin for treatment of presumed pneumonia DISEASE and referred
to the Emergency Room. In the Emergency Room the patient had
a temperature of 100.8 and was hypotensive DISEASE with a systolic
blood pressure of 77. In addition the patient was in mild
respiratory distress DISEASE and was hypoxic with an oxygen
saturation of 88% on 4 liters. The patient was diagnosed
with presumed sepsis DISEASE from pneumonia DISEASE and started on
intravenous fluid resuscitation and sent to the Intensive
Care Unit.

PAST MEDICAL HISTORY: 1. NonHodgkin's lymphoma as per
history of present illness follicular. 2. Type 1 diabetes DISEASE .
3. Benign prostatic hypertrophy DISEASE . 4. Anemia. 5.
Depression DISEASE .

MEDICATIONS ON ADMISSION:
1. Celexa 20 mg p.o. q.d.
2. Aranesp 100 mcg q. weekly
3. Colace 100 mg p.o. b.i.d.
4. Lantis insulin 10 units q. PM
5. Prevacid 30 mg p.o. q.d.
6. Magnesium oxide 400 mg p.o. q.d.
7. Remeron 15 mg p.o. q.h.s.
8. Multivitamin one tablet p.o. q.d.
9. Senna two tablets p.o. q.d.
10. Levaquin 500 mg p.o. q.d. started on [**2139-12-16**]. Humalog sliding scale 201 to 250 2 units 251 to 300 4
units 301 to 350 6 units 351 to 400 8 units 401 to 450 12
units 451 to 500 15 units.

ALLERGIES: Rituxan.

SOCIAL HISTORY: The patient is single has no children. The
next closest [**Doctor First Name **] is his brother. Lives alone prior to recent
illnesses.

PHYSICAL EXAMINATION ON ADMISSION: General: Alert and
oriented to person hospital and year but drowsy. Head
eyes ears nose and throat oropharynx with dry mucous
membranes no jugulovenous distension. Cardiovascular
regular rate and rhythm with no murmurs. Lungs with crackles
at bases bilaterally. Abdomen soft nontender
nondistended. Positive hepatomegaly DISEASE . Spleen not palpated.
Extremities no edema DISEASE 2Admission Date: [**2130-12-15**] Discharge Date: [**2130-12-21**]

Date of Birth: [**2057-10-30**] Sex: M

Service: Medicine

ADDENDUM TO [**2130-12-18**] DISCHARGE SUMMARY - SUMMARY OF HOSPITAL
COURSE FOLLOWING MICU CALL OUT: In summary this is a
73-year-old male with a history of non-Hodgkin's lymphoma DISEASE
cord compression depression DISEASE BPH who was transferred to
[**Hospital1 18**] for sepsis DISEASE and respiratory failure DISEASE treated in the ICU
and called out to the floor with resolving respiratory
failure sepsis DISEASE with a presumed pneumonia DISEASE . Please see above
dictation for ICU course.

1) SEPSIS: The patient was called out from the MICU with
resolving sepsis DISEASE . He remained hemodynamically stable on the
floor. The patient finished his 7-day course of
hydrocortisone was continued on Levofloxacin IV with
transition to PO and continued on vancomycin. Sepsis was
presumed to be due to underlying pneumonia DISEASE as evidenced by
chest x-ray though no organisms was ultimately identified in
either the blood sputum or urine. Prior PICC line site
catheter tip was also negative.

2) PNEUMONIA: The patient was treated for bilateral
interstitial fluffy infiltrates on chest x-ray. Differential
diagnosis including atypicals and PCP. [**Name10 (NameIs) **] patient improved
clinically on broad-spectrum antibiotics initially and
subsequently continued on Levaquin and vancomycin. There was
some initial suggestion that the chest x-ray looked
consistent with PCP [**Name10 (NameIs) 3**] the patient had been on long-term
steroids for cord compression DISEASE . However the patient
clinically improved without bactrim or treatment for his
Pneumocystis carinii DISEASE for suspected PCP [**Name Initial (PRE) 1064**]. The
patient will be discharged on a 7-day course of Levofloxacin
500 mg po qd and vancomycin 1 gm IV q 12 h x 7 days. The
patient will be discharged on prophylactic dose of bactrim
as the patient will continue decadron 4 mg po qd for cord
compression and for continued treatment of non-Hodgkin's lymphoma DISEASE . On discharge the patient was breathing
comfortably on room air with resolved respiratory failure DISEASE .

3) TYPE 2 DIABETES INSULIN DEPENDENT: The patient's blood
sugars were relatively uncontrolled during his hospital stay
as the patient was given IV steroids as part of the sepsis DISEASE
protocol. The patient's Lantus dose was increased to 20 U q
hs with an aggressive Humalog sliding scale and on the day
of discharge blood sugars remained in the 150s-250 range.
The patient will need careful follow-up as high-dose steroids
will be discontinued on the day of discharge with assessment
of blood sugar and need to titrate down on the Lantus and
Humalog as needed.

4) NON-HODGKIN'S LYMPHOMA: The patient will be continued to
be followed at [**Hospital1 **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for continued
management of his non-Hodgkin's lymphoma DISEASE . The patient will
be discharged on decadron 4 mg po qd.

5) ANEMIA: The patient was transfused 2 units for acute
blood loss DISEASE in the ICU. The patient's hematocrit remained
greater than 30. On discharge the patient will continue his
Epogen 4000 units twice a week for persistent and chronic
anemia DISEASE .

6) DEPRESSION: The patient's affect was relatively flat with
some evidence of paranoia. He will continue on his
citalopram 20 mg po qd with follow-up with his primary care
physician for further management.

7) DECONDITIONING: The patient has a long history of
rehabilitation inactivity and loss of function secondary to
cord compression DISEASE . Cord compression has improved per
information from his prior extended care facility. He will
need aggressive physical therapy and occupational therapy at
his new extended care facility.

DISCHARGE CONDITION: Stable. The patient is breathing
comfortably on room air attempting ambulation with
assistance and tolerating PO.

DISCHARGE STATUS: The patient is expected to be discharged
to the [**Hospital1 **] acute care facility for rehabilitation with
transfer to lower level care as needed.

DISCHARGE DIAGNOSES:
1. Sepsis DISEASE .
2. Respiratory failure DISEASE .
3. Pneumonia DISEASE bacterial unspecified.
4. Type 2 diabetes DISEASE uncontrolled.
5. Anemia DISEASE acute blood loss DISEASE .
6. Lymphoma DISEASE .
7. Failure to thrive and deconditioning.

DISCHARGE MEDICATIONS:
1. Tylenol 325-650 mg po q 4-6 h prn pain DISEASE .
2. Pantoprazole 40 mg po qd.
3. Heparin subcu 5000 U q 8 h.
4. Citalopram 20 mg po qd.
5. Mirtazapine 50 mg po q hs.
6. Epoetin Alfa 4000 U 2 x week--Monday Thursday.
7. Colace 100 mg po bid--hold for loose stools.
8. Senna 1-2 tabs po bid--hole for loose stools.
9. Levofloxacin 500 mg po qd x 7 days.
10.Lantus 20 U subcutaneous at bedtime.
11.Humalog sliding scale.
12.Decadron 4 mg po qd.
13.Bactrim 1 tab qd for PCP [**Name Initial (PRE) 1102**].

FOLLOW-UP:
1. The patient will continue to have his oncology care
coordinated via Dr. [**First Name (STitle) **] at [**Hospital1 **].
2. The patient will have a new primary care physician [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Name (STitle) 1299**] at [**Company 191**] Associates telephone# ([**Telephone/Fax (1) 1300**].
First appointment is [**2131-1-22**] at 1:30 pm at [**Hospital3 1301**].




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**] M.D.

Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36

D: [**2130-12-21**] 11:06
T: [**2130-12-21**] 11:17
JOB#: [**Job Number 1304**]
Admission Date: [**2166-11-11**] Discharge Date: [**2166-11-13**]

Date of Birth: [**2110-4-10**] Sex: M

Service: [**Company 191**] MED.

CHIEF COMPLAINT: Hematocrit drop from 30 to 23 over the
period of one week.

HISTORY OF THE PRESENT ILLNESS: This a 56-year-old male with
end-stage renal disease DISEASE status post cadaveric renal
transplant times three with recent ileostomy reversal on
[**2166-10-21**]. He presents with generalized fatigue DISEASE and
decreased hematocrit from 30 to 23 over one week while in
rehabilitation. The patient's history dates back to [**6-13**]
at which time he underwent colonoscopy for bleeding DISEASE polyps
which was complicated by valve perforation DISEASE of the cecum. He
was taken to the operating room for emergent right ileal
cystectomy with Hartmann pouch and end ileostomy in the right
lower quadrant. The patient underwent ileostomy reversal on
[**2166-10-21**] without complication. The patient returned to
[**Hospital1 69**] on [**2166-10-31**] two days
after discharge from the hospital with complaints of nausea DISEASE
vomiting DISEASE and bloating DISEASE . He was felt to have postoperative
ileus DISEASE . He was discharged to rehabilitation on [**2166-11-5**].
At rehabilitation he was noticed to have a decreased
hematocrit as well as fatigue DISEASE . He had no chest pain DISEASE
shortness of breath DISEASE or light headedness DISEASE no melena DISEASE no
hematochezia DISEASE no nausea vomiting DISEASE or abdominal pain DISEASE no
fevers chills DISEASE or rash DISEASE .

Examination revealed the patient afebrile with a heart rate
of 72 blood pressure of 162/64. He had heme-positive brown
stool. He had NG lavage of 600 cc showing stomach contents
and negative for blood. The patient was also noted to have a
calcium of 5.9 at that time. However he did have a low
albumin. He also had a positive urinalysis. He received one
unit of packed red cells in the emergency department. He
also received 2-g of calcium gluconate.

PAST MEDICAL HISTORY:
1. Renal transplant cadaveric times three in [**2134**] [**2158**]
and [**2161**] on chronic immunosuppression including
cephalosporins steroids and CellCept.
2. Chronic renal insufficiency DISEASE .
3. Coronary artery disease status post MI in [**2160**] status
post stent.
4. Peripheral neuropathy secondary to hemodialysis.
5. Gastroesophageal reflux disease.
6. Bilateral hip replacement and left shoulder replacement
secondary to steroid-induced DISEASE avascular necrosis.
7. Right foot cellulitis DISEASE on 6/[**2164**].
8. Hypertension DISEASE .
9. Hemicolectomy as per history of present illness.
10. Echocardiogram [**3-/2163**] showed akinesis of the
inferoposterior wall mild LV dilation EF 40% to 45%.
11. History of alcohol abuse.
12. History of seizures DISEASE .
13. Status post subtotal parathyroidectomy.

SOCIAL HISTORY: The patient is currently staying [**Hospital 1315**] Rehabilitation. He does not smoke. He is a former
binge drinker. He quit in [**2160**]. He is single.

FAMILY HISTORY: History is positive for stroke DISEASE in a
grandparent.

MEDICATIONS:
1. Cyclosporin 175 mg in the morningAdmission Date: [**2168-1-27**] Discharge Date: [**2168-2-3**]

Date of Birth: [**2110-4-10**] Sex: M

Service:

HISTORY OF THE PRESENT ILLNESS: The patient is a 57-year-old
man with complaints of lower leg weakness times two years.
He had a T12-L3 laminectomy done by Dr. [**Last Name (STitle) 1338**] two years ago
and however has had left leg pain DISEASE and weakness DISEASE persistently
since that surgery. He saw Dr. [**Last Name (STitle) 1327**] in [**2167-11-13**]
with complaints of pain DISEASE originating in his midback and
radiating down both legs with pain DISEASE especially in the left leg
and worsening right leg. He has also complained of numbness DISEASE
in the left leg worse than the right. The numbness DISEASE includes
both legs and thighs. He says occasionally it is hard to
initiate urination DISEASE . Also he has had urinary frequency.

PAST MEDICAL HISTORY:
1. Cholecystectomy.
2. GERD.
3. Subtotal parathyroidectomy.
4. Status post L5 laminectomy with fusion.
5. Hepatitis C.
6. Status post UTIs DISEASE .
7. Hypertension DISEASE .
8. CAD.
9. MI in [**2160**].
10. Renal failure DISEASE status post cadaveric renal transplant
times three most recently in [**2161**].
11. Coronary artery stent on the right.
12. Bilateral hip replacements.
13. Anemia DISEASE .

PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Stable. He
was afebrile. He was awake alert and oriented times three.
His pupils were equal round and reactive to light. EOMs
full. Face symmetric. His strength in his lower extremities
revealed that he was 4- in the right IP 4Admission Date: [**2119-5-4**] Discharge Date: [**2119-5-25**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Amlodipine

Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
81 yo F smoker w/ COPD DISEASE severe TBM s/p tracheobronchoplasty [**5-5**]
s/p perc trach [**5-13**]

Major Surgical or Invasive Procedure:
bronchoscopy 3/314/23[**6-12**] [**5-17**] [**5-19**]
s/p trachealplasty [**5-5**]
percutaneous tracheostomy [**5-13**] after failed extubation
down size trach on [**5-25**] to size 6 cuffless


History of Present Illness:
This 81 year old woman has a history of COPD DISEASE . Over the past five

years she has had progressive difficulties with her breathing.
In
[**2118-6-4**] she was admitted to [**Hospital1 18**] for respiratory failure DISEASE
due
to a COPD DISEASE exacerbation. Due to persistent hypoxemia DISEASE she
required
intubation and a eventual bronchoscopy on [**2118-6-9**] revealed marked

narrowing of the airways on expiration consistent with
tracheomalacia.
She subsequently underwent placement of two
silicone stents one in the left main stem and one in the
trachea. During the admission the patient had complaints of
chest
pain DISEASE and ruled out for an MI. She was subsequently discharged to

[**Hospital1 **] for physical and pulmonary rehab. Repeat bronchoscopy
on
[**2118-8-1**] revealed granulation tissue at the distal right lateral
wall of the tracheal stent. There was significant malacia of the

peripheral and central airways with complete collapse of the
airways on coughing and forced expiration. Small nodules were
also noted on the vocal cords. She has noticed improvement in
her
respiratory status but most recently has been in discussion
with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] regarding possible tracheobronchial plasty

with mesh. Tracheal stents d/c [**2119-4-19**] in anticipation of
surgery.
In terms of symptoms she describes many years of intermittent
chest pain DISEASE that she describes as left sided and occurring at any

time. Currently she notices it about three times a week and
states that it seems to resolve after three nitroglycerin.
She currently is dependent on oxygen and wears 1.5-2 liters
around the clock. She has frequent coughing and brings up Admission Date: [**2131-6-28**] Discharge Date: [**2131-7-5**]

Date of Birth: [**2060-12-25**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Mr. [**Known lastname 2302**] is a 70 y.o. male with hx of Crohn's disease DISEASE afib
dilated CMP DISEASE and PE (on coumadin) who presents with
hematochezia/BRBPR in setting of INR 7.7.

Major Surgical or Invasive Procedure:
Colonoscopy w/ multiple Bx

History of Present Illness:
Patient had felt well during the last 2 weeks prior to
admission although he had noticed slightly red/pink tinge to
his stool occasionally. Three days prior to admission pt had
an INR of 2.7 at coumadin clinic. One day prior to presenation
the patient self-started asacol from previous prescription
because worsening of rectal chrone's disease. On day of
presentation pt began having dark red bloody BMs had Admission Date: [**2130-12-24**] Discharge Date: [**2130-12-31**]

Date of Birth: [**2051-1-26**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Amiodarone / Quinidine / Procainamide / Quinine / Codeine

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
hypotension hyperkalemia DISEASE

Major Surgical or Invasive Procedure:
Hemodialysis catheter placement

History of Present Illness:
Mr. [**Known lastname 1349**] is a 78-year-old male with a history of ventricular
fibrillation arrest DISEASE in [**2108**] status post ICD placement dilated
cardiomyopathy DISEASE
atrial fibrillation hypertension DISEASE and CVA DISEASE who presented to the
[**Hospital1 18**] ED complaining of 8 lb weight gain DISEASE with increased edema DISEASE of
LE over one week despite compliance with medications. Decreased
po intake over past week. No SOB chest pain syncope fatigue DISEASE .
Found to be hypotensive DISEASE and hyperkalemic DISEASE in the ED. ROS
positive for epistaxis DISEASE (was taking Afrin for this) occasional
nausea DISEASE and nonbloody/nonbilious vomitting.

Past Medical History:
1. Ventricular fibrillation arrest DISEASE in [**2108**] - has had ICD
placement.
2. Dilated cardiomyopathy DISEASE . Echocardiogram in [**2126-2-27**]
showed an ejection fraction of 20% with inferoapical
hypokinesis plus right ventricular hypokinesis.
3. Atrial fibrillation DISEASE status post DC cardioversion in
[**2114**] on coumadin.
4. Hypertension DISEASE .
5. Hypothyroidism.
6. Cerebral vascular accident in [**2117**].
7. Rheumatoid arthritis DISEASE .
8. Positive lupus DISEASE anticoagulant.


Social History:
Mr. [**Known lastname 1349**] lives with his wife. [**Name (NI) **] denies any tobacco or drug
use. He does note occasional alcohol use.


Physical Exam:
T 97.0. Blood pressure 84/54. Heart rate 81. Respiratory rate
10. Oxygen
saturation 100% on RA DISEASE . In general in no acute
distress alert and oriented times three overweight DISEASE man. Head
eyes ears nose and throat: Normocephalic atraumatic. Pupils
are equal
round and reactive to light and accommodation. Oropharynx
is pink without lesions mucous membranes dry DISEASE . Nares with dry blood. DISEASE Neck is supple. Unable to determine JVD secondary to
excess soft tissue at neck. No lymphadenopathy DISEASE . Chest clear to
auscultation
bilaterally. Cardiovascular: RRR S1 S2
are faint. A 2/6 systolic ejection murmur DISEASE at the apex.
Abdomen soft nontender nondistended. Extremities: 1Admission Date: [**2168-4-5**] Discharge Date: [**2168-4-20**]

Date of Birth: [**2127-1-17**] Sex: M

Service: ORTHOPAEDICS

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Transferred from OSH intubated with progressive loss of
function. Found to have cerivcal discitis DISEASE epidural abscess
pharangeal abscesses DISEASE and bacteremia DISEASE .

Major Surgical or Invasive Procedure:
[**2168-4-5**] C5-T1 lami for epidural abscess - White
[**2168-4-8**] ACDF posterior I&D
[**2168-4-11**] C3-T1 PISF L ICBG Incisional Vac
[**4-14**] Trach and PEG
[**4-18**] Right PICC line placement


History of Present Illness:
HPI: 41M h/o IVDA with 3d progressive neck and upper back pain DISEASE
and 1d of rapidly progressive UE/LE weakness numbness.
Progressive symptosm [**4-7**] with epidural abscess DISEASE on MRI


Past Medical History:
Not Known

Social History:
Living with a friend. [**Name (NI) 1351**] no children. On SSI benefits for
asthma DISEASE and neuropathy DISEASE . Smokes occasional cigarettes no EtOH.


Family History:
Parents with DM. Father with [**Name2 (NI) 499**] CA.

Physical Exam:
Trach in place
Anterior Posterior ICBG wounds clean and dry
C5 3/5 strength
C6 3/5 strength
SITIL grossly BUE and BLE
C7-S1 No demonstrated motor

Pertinent Results:
[**2168-4-5**] 04:56PM TYPE-ART PO2-95 PCO2-34* PH-7.45 TOTAL CO2-24
BASE XS-0
[**2168-4-5**] 04:56PM freeCa-1.04*
[**2168-4-5**] 08:13AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.032
[**2168-4-5**] 08:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2168-4-5**] 08:13AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-Admission Date: [**2174-8-31**] Discharge Date: [**2174-9-2**]

Date of Birth: [**2115-1-22**] Sex: F

Service: NSU


PRIMARY DIAGNOSIS: Right middle cerebral artery aneurysm DISEASE .

HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1356**] is a pleasant 59-year-
old woman who had previously seen Dr. [**Last Name (STitle) 1132**] in clinic. She
had previously had an MRI for work-up of questionable TIA DISEASE
spells. She describes episodes of lightheadedness
dizziness DISEASE as well as right leg weakness DISEASE when climbing
stairs. Ultimately she was found to have a right MCA
aneurysm DISEASE . She presents to the [**Hospital1 **] [**First Name (Titles) **]
[**Last Name (Titles) 1357**] coiling of her aneurysm DISEASE and angiogram.

PAST MEDICAL HISTORY: Fibromyalgia dysplasia DISEASE .

Gastroesophageal reflux DISEASE .

Esophagitis DISEASE .

Depression DISEASE .

Arthritis DISEASE .

History of epistaxis DISEASE .

PAST SURGICAL HISTORY: Status post [**Last Name (un) 1358**] fundoplication in
[**2162**].

Status post cholecystectomy.

Status post hysterectomy.

Status post varicose vein ligation.

Status post left knee surgery.

MEDICATIONS AT HOME:
1. Nicotine 21 mg TD DISEASE qd.
2. Zofran.
3. Colace.
4. Nortriptyline.
5. Trazodone.


COURSE IN HOSPITAL: The patient was admitted for [**Year (4 digits) 1357**]
coiling of right MCA aneurysm. She was taken to the
operating room on [**2174-8-31**]. She was placed under
general anesthesia and intubated. She tolerated the
procedure well with no complications. The angiogram showed
right MCA aneurysm confirming the preop diagnosis. There
was a 4 mm right MCA bifurcation aneurysm DISEASE that was coiled
using GDC and Matrix coils. She tolerated the procedure well
without complications. She was extubated and then brought to
the recovery room.

Postoperatively she remained afebrile with stable vital
signs. She was following all commands and doing well. She
had some slight weakness on the left leg. She received 3
days of aspirin. The left leg was not in the cerebral territory
that was treated. Accordingly a spinal MRI was obtained which
was negative.

Her postoperative left leg weakness resolved by postop day
2. She continued to have gradual improvement until full
recovery was obtained. Her course in the hospital otherwise
remained uneventful. She remained afebrile with stable vital
signs. She was transferred out of the unit on postoperative
day 1. She was alert and oriented throughout. She had equal
and symmetric pupils. She had a symmetric face with full
extraocular movements DISEASE . Her tongue was midline. She had no
drift. She had full grips. She had no hematoma DISEASE . She had
good distal pulses.

Her lines were removed when she was transferred to the floor.
She was ambulating independently. Given her left lower
extremity weakness she was planned for a screening MRI of
the lumbar spine as well as cervical and thoracic sagittal DISEASE
images.

The patient was currently stable for discharge home. She was
doing well and tolerating good PO intake. She had been
ambulating independently. She had been voiding independently
without difficulty. She had been asked to call Dr [**Last Name (STitle) 1132**] in 1-
2 weeks. She was continued on her preop medication.



[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**] [**MD Number(1) 1360**]

Dictated By:[**Last Name (NamePattern1) 1361**]
MEDQUIST36
D: [**2174-9-2**] 09:49:13
T: [**2174-9-2**] 10:30:55
Job#: [**Job Number 1362**]
Admission Date: [**2197-11-27**] Discharge Date: [**2197-12-1**]

Date of Birth: [**2130-8-26**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Horse Blood Extract / Bactrim Ds / Adhesive Tape / Sulfa
(Sulfonamides)

Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Somnolence DISEASE .

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
This is a 67 y.o male with bladder cancer DISEASE with large pelvic
masses recent chemo tue (taxol gemzar) now presenting with
n/v/d/ new afib with RVR metastatic disease. Pt is HD m/w/f
.
Pt denies pain DISEASE but is unable to report other ROS. States he's
tired.
.
In the [**Name (NI) **] pt at first refused IV got EJ removed it an
another was placed. Pt s/p 3L IVF. HR 100-170's not given any
nodal agents for rate control. PT found to be neutropenic DISEASE .
RUQ-new liver masses/sacral/iliac R.sided hydroureter has
neobladder. Pt given vanco cefepime flagyl. Somnolent head CT
negative. Tmax 100.2
.


Past Medical History:
CAD
HTN DISEASE
Hyperlipidemia DISEASE
ESRD DISEASE on HD DISEASE
Bladder Cancer DISEASE in [**2181**]
Depression DISEASE
Restless DISEASE Leg Syndrome


Social History:
Patient lives at home with girlfriendAdmission Date: [**2119-1-17**] Discharge Date: [**2119-3-31**]

Date of Birth: [**2073-3-6**] Sex: M

Service: SURGERY

Allergies DISEASE :
Penicillins / Zofran / Toradol / Phenobarbital / Trazodone /
Compazine / Oxycodone

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
encephalopathy DISEASE

Major Surgical or Invasive Procedure:
Blood transfusion
Paracentesis x2 ([**1-17**] [**1-23**])
[**2119-3-14**] liver transplant


History of Present Illness:
45 y/o male with ESLD DISEASE from HCV HBC DISEASE and EtOH who had a TIPS
done on [**2119-1-5**] who presented to the OSH yesterday with altered
mental status. The patient was treated with lactulose at the OSH
with some improvement in his encelpalopathy. There was concern
that there was a problem with the TIPS and he was transferred to
[**Hospital1 18**] for further workup.
Denied chest pain shortness of breath fevers chills DISEASE . He
reports abdominal pain DISEASE slightly worse than his baseline. No
melena DISEASE or BRBPR.
.
Labs at the OSH significant for AST/ALT DISEASE 186/124 TB 12 DB 5
Ammonia 330 Na 132.


Past Medical History:
# L4L5S1 fusion
# Decompensated liver cirrhosis DISEASE [**1-28**] to HCV HBC and alcohol c/b
encephalopathy DISEASE and ascites DISEASE
# Chronic pancreatitis DISEASE
# Non bleeding DISEASE grade 2 esophageal varices DISEASE in [**4-3**]
# GERD-Barrett's esophagus
# COPD DISEASE
# s/p incarcerated umbilical hernia DISEASE repair [**11-3**] recent
admission on [**2118-12-26**] to [**2118-12-30**] for concern for cellulitis DISEASE
around his surgical incision started on clindamycin then vanc
then bactrim for a total course of 7 days
#OLT [**2119-3-14**]


Social History:
Married but separated has 3 children. Lives with roommates -
limited support. Smokes a pack every 3 days. Quit cocaine and
heroine in [**2114**]. Quit EtOH in [**2101**].


Family History:
Family Hx: No known family history of hepatitis DISEASE or liver
disease

Physical Exam:
VS: 97.5 95/69 90 12 93%RA
Gen: awake oriented x 2 (able to state month and year stated
he was at BAdmission Date: [**2103-3-7**] Discharge Date: [**2103-3-13**]


Service: SURGERY

Allergies DISEASE :
Codeine / Aspirin / Ibuprofen / Lipitor / Crestor

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
fall down stairs syncope DISEASE

Major Surgical or Invasive Procedure:
Paravertebral block DISEASE by Acute Pain DISEASE Service


History of Present Illness:
This is a [**Age over 90 **] y/o F with h/o previous C7 vertebral body
compression fx last year after a syncopal DISEASE event while
defecating who presents to [**Hospital1 18**] ED after falling down flight
of stairs today. Pt was carrying laundry up a flight of stairs
and fell when she had a syncopal DISEASE event. Pt aroused at bottom of
stairs and called for help. At presentation she complained of
right sided back pain DISEASE . She had head c-spine DISEASE and torso CT scan
which showed multiple right sided rib fractures DISEASE . Pt does have
chronic neck pain DISEASE after compression fx last year. She wears a
neck brace DISEASE as needed at night for comfort. She currently denies
neck pain headache abdominal pain DISEASE or distension and
additionally denies any chest pain DISEASE or SOB or palpitations DISEASE prior
to the fall.

Past Medical History:
PMH:
1. A-fib
2. Type II DM
3. Hx of PE 20 yrs ago
4. Hyperlipidemia DISEASE
5. Osteoporosis DISEASE
6. Osteoarthritis DISEASE
7. Anxiety DISEASE
8. C7 compression fracture DISEASE s/p fall

PSH DISEASE : None

Social History:
Patient lives at home engages in water aerobics everyday
denies use of tobacco alcohol or IV drug use


Family History:
Father died from MI at age 50
Brother died from MI at age 37

Physical Exam:
At discharge
VS: Afebrile VSS
96.2 87 158/82 16 98%2L
Constitutional DISEASE : Well appearing no acute distress
Neck: No masses
CV: RRR no murmurs.
Resp: CTAB no wheezes or crackles IS 300. Admission Date: [**2102-10-1**] Discharge Date: [**2102-10-3**]

Date of Birth: [**2019-8-6**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Quinolones

Attending:[**Doctor First Name 1402**]
Chief Complaint:
Syncope DISEASE

Major Surgical or Invasive Procedure:
[**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] pacemaker placement


History of Present Illness:
83 yo male with history of hyperlipidema hypertension DISEASE
bifascicular block DISEASE on previous EKG presented to the ED with
syncope DISEASE . The patient was feeling lightheaded this evening. He
called his daughter to discuss his symptoms. While he was on
the phone the line went dead for approx 3min. He reports he
lost consciousness during that time. His daughter called EMS.
He denied falling during the episode of LOC. When EMS arrived
he was found to be in complete heart block DISEASE with a ventricular
rate in the 20s. He was given atropine en route to the ED.
.
In the ED initial vitals were T99.0 HR 30 BP 140/60 RR18 o2
100% on NRB. He was found to be in third degree heart block DISEASE
with a continued ventricular rate in the 30s. He was given
atropine again. He sustained a brief episode of asystole DISEASE and a
temporary pacer wire was placed. He had appropriate capture and
was paced at a rate of 80bpm. He was intubated for airway
protection given fentanyl and midazolam for sedation then
changed to propofol prior to transfer.
.
Unable to obtain review of systems secondary to sedation.

Past Medical History:
1. CARDIAC RISK FACTORS: (Admission Date: [**2103-6-19**] Discharge Date: [**2103-6-24**]

Date of Birth: [**2019-8-6**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Penicillins / Quinolones

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**2103-6-19**] Coronary bypass grafting times 4(left internal mammary
artery to left anterior descending artery reverse saphenous
vein graft to right coronary arterysequential reverse saphenous
vein graft to first and second obtuse marginal arteries).
Permanent left ventricular epicardial lead placement


History of Present Illness:
This 83 year old white male with complaints of dyspnea DISEASE on
exertion and abnormal stress echo was referred for cardiac
catheterization. This revealed severe coronary artery disease DISEASE
and he was referred for surgical intervention.

Past Medical History:
Hypertension DISEASE
Hyperlipidemia DISEASE
s/p St. [**Male First Name (un) 923**] PPM for CHB DISEASE [**9-15**]
Arthritis DISEASE
Sleep apnea DISEASE noted after administration of narcotics
Diverticulitis DISEASE s/p Left hemicolectomy [**5-/2102**]
s/p Back surgery [**2101**]
s/p Appendectomy
s/p Tonsillectomy

Social History:
Race:Caucasian
Last Dental Exam:
Lives with:wife
Occupation:Retired
Tobacco:quit 23 years ago smoked x 50 years
ETOH:[**12-9**] pint of hard alcohol a day

Family History:
noncontributory

Physical Exam:
admission:
Pulse:70 Resp:13 O2 sat:97% RA DISEASE
B/P Right:156/662 Left:160/64
Height:5'1Admission Date: [**2103-7-18**] Discharge Date: [**2103-7-31**]

Date of Birth: [**2019-8-6**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Penicillins / Quinolones

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Sternal drainage

Major Surgical or Invasive Procedure:
[**2103-7-18**] Sternal debridement with placement of VAC dressing.
[**2103-7-23**] Removal of infected epicardial pacing leads. Closure of
the sternal wound dehiscence with four Synthes plates bilateral
pectoralis musculocutaneous advancement flap.


History of Present Illness:
83-year-old male who underwent coronary artery bypass grafting
along with placement of epicardial pacing wires on [**2103-6-19**].
He had been doing fairly well until 3 or 4 days prior to
admission when he began having some drainage from his sternal
incision. Upon examination on the day of admission he had
purulent drainage from the sternal incision and he also
commented that he noted a sternal click recently. Based upon
clinical findings he was admitted for sternal exploration.

Past Medical History:
Coronary Artery Disease
Hypertension DISEASE
Hyperlipidemia DISEASE
s/p St. [**Male First Name (un) 923**] PPM for CHB DISEASE [**9-15**]
Arthritis DISEASE
Sleep apnea DISEASE noted after administration of narcotics
Diverticulitis DISEASE s/p Left hemicolectomy [**5-/2102**]
s/p Back surgery [**2101**]
s/p Appendectomy
s/p Tonsillectomy

Social History:
Lives with: Wife
Occupation: Retired
Tobacco: Quit 23 years ago smoked x 50 years
ETOH: [**12-9**] pint of hard alcohol per day


Family History:
Noncontributory

Physical Exam:
HR 83 B/P R 89/49 L 87/52 DISEASE RR 16 RA DISEASE sat 98%

General:having pain DISEASE in neck and shoulders traveling down left
back
Cardiac: RRR [x] Irregular [] Murmur-none
Chest: Lungs clear bilateral [x]
Abdomen: Soft [x] Nontender [x] Nondistended [x]
Extremities: Warm [x] Well perfused [x]
Edema: Right-none Left-none
Sternal incision:frank pus draining with erythema DISEASE afebrile
erythema DISEASE no[] yes[x] drainage no[] yes[x] well approximated yes [x] no [] sternal click no[x] yes[] EVH site: RLE [] LLE [x] erythema no[x] yes[] drainage no[x] yes[] Pertinent Results:
[**2103-7-18**] WBC-15.4*# RBC-3.51* Hgb-10.9* Hct-32.8* Plt Ct-239#
[**2103-7-18**] PT-13.2 PTT-34.8 INR(PT)-1.1
[**2103-7-18**] UreaN-72* Creat-3.5*# Na-133 K-5.3* Cl-99 HCO3-22
AnGap-17
[**2103-7-31**] 05:00AM BLOOD WBC-10.8 RBC-2.81* Hgb-8.5* Hct-26.2*
MCV-93 MCH-30.1 MCHC-32.3 RDW-16.4* Plt Ct-704*
[**2103-7-31**] 05:00AM BLOOD Plt Ct-704*
[**2103-7-31**] 05:00AM BLOOD PT-14.7* INR(PT)-1.3*
[**2103-7-31**] 05:00AM BLOOD UreaN-49* Creat-1.1 Na-139 K-4.8 Cl-107
[**2103-7-29**] 05:38AM BLOOD Glucose-75 UreaN-44* Creat-1.5* Na-142
K-3.5 Cl-110* HCO3-23 AnGap-13

[**2103-7-23**] 10:00 am FOREIGN BODY PACING WIRES.

**FINAL REPORT [**2103-7-26**]**

WOUND CULTURE (Final [**2103-7-26**]):
STAPH AUREUS COAG DISEASE Admission Date: [**2103-8-7**] Discharge Date: [**2103-8-24**]

Date of Birth: [**2019-8-6**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Quinolones / Cefazolin

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Acute Hypercarbic Respiratory Distress

Major Surgical or Invasive Procedure:
Bilateral thoracenteses
S/p removal of chest wall drain


History of Present Illness:
Mr. [**Known lastname 14**] is an 84 year old gentleman with a PMH significant
for recent CAD s/p CABG c/b sternal wound infection DISEASE on
antibiotics and CHB DISEASE s/p PPM admitted for a lower extremity rash DISEASE
concerning for vasculitis DISEASE and acute renal failure DISEASE . The patient
underwent CABG in [**6-16**] and was re-admitted to [**Hospital1 18**] on [**2103-7-18**]
for sternal wound exploration with a drain placed with cultures
speciated as MSSA. At that time he was discharged on cefazolin
with the plan for a prolonged 8 weeks of antimicrobial therapy.
On [**8-6**] the ID service was contact[**Name (NI) **] as the patient had
developed a rash DISEASE over his lower extremities concerning for a
drug rash DISEASE by his physician at rehab. At that time given that he
has a history of an unknown PCN reaction he was converted to
vancomycin. Today he presented to the [**Hospital 18**] [**Hospital **] clinic and was
found to have a rash DISEASE concerning for vasculitis DISEASE and ARF DISEASE with a
creatinine of 2 and a serum potassium of 5.7. He was then
referred to the ED for futher management.
.
In the [**Hospital1 18**] ED initial VS 97.7 60 133/48 20 95%RA. ECG was
negative for peaked T waves the patient received 30 mg
kayexalate had a negative CXR and was admitted to Medicine for
further management. On ROS the patient reports that he has
been feeling increasingly fatigued over the past week with
decreased PO intake but denies any f/c/s n/v/d abd pain DISEASE HA
palpitations DISEASE . He is does not know when his rash DISEASE developed.
.
On the floor pt Cr 2.0--Admission Date: [**2131-7-5**] Discharge Date: [**2131-7-24**]

Date of Birth: [**2060-12-25**] Sex: M

Service: SURGERY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
New diagnosis Colon Cancer DISEASE

Major Surgical or Invasive Procedure:
[**2131-7-11**]: ERCP with sphincterotomy
[**2131-7-16**]: laparoscopic right colectomy


History of Present Illness:
Mr. [**Known lastname 2302**] is a 70 y.o. male with hx of Crohn's disease DISEASE afib
dilated CMP h/o PE who presents after recent discharge due to
colon biopsies found positive for Colon Cancer DISEASE . Pt recent
admission was for bloody stools DISEASE and significantly elevated INR.
During this admission he had colonoscopy with multiple biopsies.
He was discharged in stable condition without any IBD DISEASE meds and
without anticoagulation. He was called by PCP and told to come
back due to positive colon biopsy and need for further
staging/workup. Pt denies any grossly bloody stools at home
has not been taking any meds and has been tolerating po well
with minimal rectal pain DISEASE .

Past Medical History:
1. Crohn's DISEASE dz found in [**2125**] on colonoscopy for anal fissure DISEASE
positive [**Doctor First Name **] been treated with Remicade
2. Rheumatoid arthritis DISEASE
3. HTN DISEASE
4. hx of renal calculus
5. s/p appendectomy
6. s/p TURP
7. s/p cholecystectomy
8. Recent pulmonary embolism- on coumadin since [**2-12**]
9. LVH LV enlargement apical LV aneurysm DISEASE with LV thrombus DISEASE EF
25%
10. Chronic left knee pain DISEASE s/p meniscectomy synovectomy and
debridement of left knee [**2123**]
11. Recent gallstone pancreatitis DISEASE [**2-12**]
12. Afib DISEASE - [**2-12**] rate controlled on atenolol


Social History:
Married for 46 years and lives with wife. 3 children who all
live in area. No tobocco h/o occasional ETOH stopped drinking
in [**11-13**] denies h/o ETOH abuse. No illicit drugs.


Family History:
Father died at 62 from MI
Mother died at 52 of cirrhosis DISEASE
No cancer DISEASE or diabetes DISEASE to patient's knowledge
No history of clotting disorders DISEASE

Physical Exam:
T-96.8 BP-140/70 P-96 RR-20 Sats-95% on RA DISEASE
Gen: NAD comfortable
HEENT: NCAT EOMI MMM oropharynx
CV: irreg/irreg no m/r/g no JVD
RESP: CTAB no w/r/crackles
ABD: soft/NT/ND/NABS
EXTR: no c/c/edema Admission Date: [**2103-8-30**] Discharge Date: [**2103-9-13**]

Date of Birth: [**2019-8-6**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Quinolones / Cefazolin

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
CVVH
Hemodialysis
Tunneled HD catheter placement

History of Present Illness:
84 yo m hx of CHF DISEASE EF of 40% who was transfered form rehab due to
worsening of SOB and ARF DISEASE . He was recetly admitted from
[**Date range (1) 1424**] and discharge to rehab. He was on lasix 80mg [**Hospital1 **] then
2 days ago lasix was adjusted to 80mg AM and 40mg PM. Per rehab
his Cr has been trendeding up and his dypsnea has been
worsening. At discharge his Cr was 0.9 then 1.1 and now 2.2
today. UO has been decreased per pt. Wt gains of 2 lbs over last
few days.
.
During his last hopsitalization he was treated for a sternal
wound infection DISEASE from his CABG on [**6-16**]. On [**7-23**] he had a
debridement and wound closer with pacer lead removal on [**7-23**].
Epicardial leads were paritally removed. Old PPM remained in
place. He also had a flap closure. Culture of his infeciton
showed MSSA. He developed AIN DISEASE so his antibiotics were changed
to vancomycin. He will be on lifelong suppresive therapy after
his regiment of IV therapy. Hardware in the sternum is in place.
His stay was complicated by CHF DISEASE and ARF DISEASE from diuresis later
this improved to a Cr of 0.9 and he was sent to rehab.
.
On review of systems he denies any prior history of stroke DISEASE
TIA DISEASE deep venous thrombosis pulmonary embolism bleeding DISEASE at the
time of surgery myalgias cough hemoptysis DISEASE black stools or
red stools. Denies recent fevers chills DISEASE or rigors DISEASE . All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain DISEASE
palpitations syncope DISEASE or presyncope DISEASE .
.
In the ED initial vitals were 96.8 67 128/58 20 94% 3L NC. Pt
was given 250mg IVF over 2 hours. Pt's oxygen was increased to
4L. On transfer temp 97.9 67 120/45 18 96% 4 liters. CXR with
pulm edema DISEASE . Pt admitted to [**Hospital Unit Name 196**].
.

Past Medical History:
-Coronary Artery Disease DISEASE s/p CABG (see below)
-Hypertension
-Hyperlipidemia
-s/p St. [**Male First Name (un) 923**] PPM for Third degree heart block DISEASE [**9-15**]
-Arthritis
-Sleep apnea DISEASE noted after administration of narcotics
-Diverticulitis s/p Left hemicolectomy [**5-/2102**]
-s/p Back surgery [**2101**]
-s/p Appendectomy
-s/p Tonsillectomy
-[**2103-7-23**] Sternal debridement closure of the sternal wound
dehiscence with four Synthes plates bilateral pectoralis
musculocutaneous advancement flap.
-ARF due to questionable AIN DISEASE due to cephalosporin or
hemodynamically mediated ARF DISEASE in [**2103-6-14**]

Social History:
-Tobacco history: quit 25 yo ago
-ETOH: 1 pint a day until CABG in [**6-16**]
-Illicit drugs: none
Lived with wife before going to rehab now using a walker

Family History:
Noncontributory

Physical Exam:
GENERAL: Some tachypea DISEASE with talking otherwise NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva were
pink no pallor or cyanosis DISEASE of the oral mucosa. No xanthalesma.

NECK: Supple with JVP at his chin while sitting at 45 degrees
CARDIAC: Difficult to hear cardiac sounds no murmur sternal
wound dressing in place small drainage
LUNGS: Resp were slightly labored pursed lip breathing DISEASE able to
speak full sentences no accessory muscle use. soft breath
sounds crackles half way up.
ABDOMEN: Soft NTND. No HSM or tenderness DISEASE . No abdominial bruits DISEASE .

EXTREMITIES: No c/c. 2Admission Date: [**2139-2-4**] Discharge Date: [**2139-2-5**]

Date of Birth: [**2078-10-16**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Diltiazem

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Epigastric pressure

Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placed in the Left anterior
descending artery.


History of Present Illness:
60 M with PMH HTN DISEASE GERD presents with epigastric pressure x 2
weeks. Pain DISEASE feels different from GERD pressure-like Admission Date: [**2169-12-30**] Discharge Date:

Date of Birth: [**2136-10-31**] Sex: F

Service: MICU

HISTORY OF PRESENT ILLNESS: This is a 33-year-old female
with a history of obesity DISEASE developmental delay seizure DISEASE
disorder depression DISEASE and ventricular septal defect DISEASE who
presented with a chief complaint DISEASE of shortness of breath DISEASE to
the [**Hospital1 69**] Emergency Department
on [**12-30**] after being initially evaluated at [**Hospital3 1442**] Hospital.

The patient's symptoms began on [**12-25**] with five days of
cough DISEASE temperatures to 101 Fahrenheit shortness of breath
and wheezing DISEASE . She went to her primary care physician three
days prior to admission where the temperature was measured at
102.2 Fahrenheit and after chest x-ray was negative for
infiltrate she was diagnosed with bronchitis DISEASE and treated with
Bactrim-DS. She took this for three days but on the day of
admission the patient was found a home health aide to be
increasingly short of breath and the patient was taken to
[**Hospital3 1443**] Hospital where she was satting 92% on 4
liters nasal cannula. A chest x-ray showed right lower lobe
infiltrate. The patient was given 125 mg of Solu-Medrol
nebulizers ceftriaxone 1 g and transferred to the [**Hospital1 1444**] where she was admitted to the
Medical Intensive Care Unit.

There the patient was found to be 87% on 4 liters nasal
cannula which improved to 93% on 100% face mask. The
patient's saturations fell to 90% on 100% face mask and BiPAP
14/4 was tried. However the patient did not tolerate the
BiPAP well despite the fact that the saturations came back to
approximately 95%.

REVIEW OF SYSTEMS: On review of systems the patient has no
history of asthma DISEASE but is a heavy smoker at two to three packs
per day for many years. Her membranous ventricular septal
defect was diagnosed on cardiac echocardiogram performed in
[**2164**].

PAST MEDICAL HISTORY:
1. Obesity.
2. Developmental delay.
3. Seizure disorder status post motor vehicle accident.
4. Depression.
5. Ventricular septal defect DISEASE .
6. Auditory hallucinations DISEASE .
7. Melanoma on chest status post excision.

ALLERGIES: RISPERIDONE causing nausea DISEASE .

MEDICATIONS ON ADMISSION: Outpatient medications include
Colace 100 mg p.o. b.i.d. Dilantin 300 mg p.o. q.a.m. and
400 mg p.o. q.p.m. Lactase 3 tablets p.o. t.i.d. with meals
lorazepam 0.5 mg p.o. t.i.d. p.r.n. perphenazine 4 mg p.o.
t.i.d. venlafaxine 150 mg p.o. q.d. Zyprexa 10 mg p.o.
t.i.d. Bactrim-DS since [**12-27**] Senna.

SOCIAL HISTORY: A two to three pack per day smoker. Lives
alone with home health services and advocate.

FAMILY HISTORY: Breast cancer DISEASE .

PHYSICAL EXAMINATION ON PRESENTATION: Temperature 99.2
Fahrenheit heart rate 110 blood pressure 140s/50s
respirations 28 to 36 oxygen saturation 93% on 100% face
mask. In general alert lying in bed obese in moderate
respiratory distress DISEASE . Head ears nose eyes and throat
revealed mucous membranes were moist. No lymphadenopathy DISEASE .
Heart was tachycardic but regular. No murmurs rubs or
gallops. Pulmonary revealed diffuse rhonchi right greater
than left prolonged expiratory phase with wheezing DISEASE
diffusely. Abdomen was soft nontender and nondistended
with normal active bowel sounds. Extremities had no edema DISEASE
no palpable cords 2Admission Date: [**2141-11-9**] Discharge Date: [**2141-11-20**]


Service: Vascular

CHIEF COMPLAINT: Chest pain DISEASE . Patient was initially
evaluated at [**Hospital 1474**] Hospital and transferred here for
further evaluation and treatment. Initial enzymes showed a
total CPK of 4120 CK MB 20 and troponin of 17.4.

PAST MEDICAL HISTORY: Coronary artery disease DISEASE status post
cath in [**2131**] showing ejection fraction of 56% with
anterolateral apical akinesis. The RCA DISEASE is 80% obstructed.
The marginal branch of the RCA was 40% obstructed with
diffuse disease. The mid LAD was 95% diagonal I was 60%.
The patient underwent angioplasty of the LAD. Patient was
noted to have mild mitral regurg. A stress test done at that
time showed dilated left ventricle with fixed defects and
anterolateral septal wall with high grade EAE DISEASE and equivocal
changes. Previous MI was 5 years prior to 92. History of
peptic ulcer disease DISEASE . No previous surgeries no known drug
allergies DISEASE .

MEDICATIONS: On transfer to our institution Lopressor 12.5
mg q 6 hours Atenolol 25 mg q d Nitro paste 1 inch q 4
hours Captopril 17.5 mg.

SOCIAL HISTORY: He is married lives in [**Location 1475**] is 66
years old is a former smoker of 40 pack years no alcohol
semi retired and helps in a welding shop.

PHYSICAL EXAMINATION: On admission vital signs 97.5
122/91 70 18 O2 saturation 98% on room air. The patient
is alert oriented and in no acute distress. HEENT: Showed
constricted pupils secondary to narcotics EOM's intact.
Soft palate elevates. No teeth in the lower mandible no
icterus DISEASE . Cardiovascular exam was a regular rate and rhythm
with no murmurs rubs or gallops. Neck without bruits DISEASE .
Lungs are clear to auscultation bilaterally. Abdomen is
unremarkable. Extremities with intact pulses.

LABORATORY DATA: On transfer included a CBC with white count
6.7 hematocrit 39.1 platelet count 196000. Electrolytes
sodium 135 potassium 4.6 chloride 100 CO2 77 BUN 11
creatinine 0.1 glucose 114 PT and INR were normal PTT were
normal. CK totals were 0 90 and peak to 412 MB were 82 and
6 MBI index was 20 troponin was 17.4. Urinalysis was
negative. EKG showed a normal sinus rhythm with a normal
axis deviation with inverted T's in V4 and V5 which were new.

HOSPITAL COURSE: The patient was admitted to the cardiology
service and was placed in Intensive Care Unit. IV Heparin
and Nitroglycerin were begun. Serial CKs were obtained along
with serial EKG's. Serial total CK's peaked at 533. MB
fraction peaked at 9.2. Initial troponin level was greater
than 50 and after the next 72 hours its level was 1.5.
Normal is less than .03. Within the next 24 hours the
patient underwent cardiac catheterization. The patient's
right sided pressures PA was 50/17 right atrial mean was
16 pulmonary wedge pressure was 16 left ventricular end
diastolic pressure was 17. Cardiac output was 6.0 index was
3.3 EF was 30% with akinetic anterolateral and apex walls
and hypokinetic antero basal wall and normal posterior and
basal wall. The native vessels showed left main trunk
disease of 30% left anterior was proximal 30% and mid 90%
left circumflex was mid 50%. Ramus intermedius was 90% which
was angioplastied and stented and the right coronary showed
an osteal lesion of 30%. There was concern of right external
iliac artery dissection. The patient underwent a right
femoral ultrasound which demonstrated triphasic flow in the
right common femoral artery with plaque DISEASE or flap proximal to
the right SFA with stenosis DISEASE and did have episodes of SVG and
was begun on beta blockers. Aspirin and Plavix were continued
post stenting. The groin was without bleeding DISEASE and he had
distal pulses. Dr. [**Last Name (STitle) **] the cardiologist requested that
vascular be consulted regarding the findings on the right
iliac SFA ultrasound. The patient although study was
abnormal but with intact distal pulses the patient did note
72 hours after catheterization onset of right calf and ankle
foot pain DISEASE with ambulation. The patient underwent a repeat
peripheral arterial catheterization which demonstrated
abdominal aorta with no significant disease renal arteries
bilaterally were normal the right lower extremity iliac is
without critical lesions the previous noted dissection is
not occlusive but the site is still delineated. The common
femoral is normal the SFA and profunda artery are normal
the popliteals occlude mid vessel and the anterior and tibial
were not well visualized but appear thrombolytically
occluded. There was three vessel runoff to the foot. The
collaterals provide much of the distal flow. The patient was
TPA'd DISEASE begun on Heparin and placed in the VICU. The patient
had consequences of a right groin hematoma DISEASE after the second
right groin intervention and angiography which required
pressure occlusion. The patient underwent on [**11-14**] a
thrombectomy of the right tibial peroneal trunk and AT artery
with patch angioplasty of the right popliteal artery. He
tolerated the procedure well and was transferred to the VICU
for continued monitoring and care. The patient required a
unit of packed cells for hematocrit of 25 post transfusion
hematocrit was 35. Total CK was 74. The patient was placed
on peri-operative Kefzol and remained in the VICU DISEASE in stable
condition. On [**11-15**] the patient had an episode of
hematemesis DISEASE . An NG was placed with 300 cc of blood
aspirated. The patient remained hemodynamically stable.
Serial hematocrits were obtained and Plavix and Aspirin were
held. GI was consulted. The patient underwent upper
endoscopy which demonstrated a few non bleeding DISEASE localized
erosions DISEASE in the esophagus at the GE junction consistent with
NG trauma. There was bilious fluid in the stomach body and
antrum. There is no active bleeding DISEASE or coffee ground or
bright red blood noted. There were few superficial non
bleeding DISEASE 2 mm ulcers DISEASE ranging in size from 2 mm to 5 mm in the
stomach. The duodenum was normal. Recommendations were to
continue the Protonix at 40 mg q d discontinue the NG tube
follow serial hematocrits. Please consider the risk/benefits
of Aspirin and Plavix. If Aspirin and Plavix need to be
continued then we will put the patient on a higher dose of
Protonix. The patient experienced episode of hypertension DISEASE
overnight on postoperative day #1 requiring adjustments in
hypertensive DISEASE medications and transfusion of packed red blood
cells. On postoperative day #3 there were no overnight
events. The patient continued on Protonix IV and Captopril
and beta blockers. His hematocrit remained stable at 29.
CKs were flat and serial hematocrits remained stable. The
patient was then begun on Aspirin. Physical therapy saw the
patient and felt that he would be able to be discharged to
home after evaluating ambulation with stairs. The patient's
hematocrits remained stable groin remained stable. The
patient was discharged in stable condition on [**2141-11-20**]. She
is to follow-up with Dr. [**Last Name (STitle) **] as instructed and see Dr.
[**Last Name (STitle) 1476**] in two weeks time.

DISCHARGE MEDICATIONS: Include Keflex 500 mg qid times 7
days Aspirin 81 mg q d Lopressor 25 mg [**Hospital1 **] hold for
systolic blood pressure less than 120 heart rate less than
60 Protonix 40 mg q d Colace 100 mg [**Hospital1 **] Percocet tablets
[**12-27**] q 4 hours prn pain DISEASE Plavix 75 mg q d.

DISCHARGE DIAGNOSIS:
1. Non Q wave MI status post angioplasty of the ramus
intermedius with stenting.
2. Right groin hematoma DISEASE stabilized.
3. Right iliac external artery dissection stabilized.
4. Thrombolic ischemia DISEASE of the right leg status post
thrombectomy of the anterior tibial and peroneal trunk.
5. Hypertension DISEASE controlled.
6. GI bleeding stabilized.
7. Blood loss anemia DISEASE transfused corrected.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**] M.D. [**MD Number(1) 1478**]

Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36

D: [**2141-11-19**] 16:01
T: [**2141-11-19**] 16:50
JOB#: [**Job Number 1480**]
Admission Date: [**2200-7-10**] Discharge Date: [**2200-7-15**]

Date of Birth: [**2150-10-11**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Colitis DISEASE with bleeding DISEASE

Major Surgical or Invasive Procedure:
Right Colectomy


History of Present Illness:
49 yo female who has had blood loss DISEASE over a period of several
months and has had abnormal colonoscopies which have shown some
areas of stricturing. This has been unusual but is thought most
likely to be due to Crohn's disease DISEASE . She has
been on steroids but still with problems. She presents now with
a hematocrit of 20. She is a Jehovah's witness and will not
accept any blood transfusions. After consultation with her
General Medical physician and also with the hematology service
it was thought that it would not be possible to increase her
hematocrit significantly prior to operation without at least a 1
month delay. It was also thought likely that any improvement in
iron therapy would be off-set by continued bleeding DISEASE . The patient
and her partner understand the gravity of this situation and the
need for operation under less than optimum circumstances. The
patient has again expressed her wish that she not be given blood
products but she would accept certain other types of fluid. She
presents
now for right colectomy.

Past Medical History:
Neuralgia
Rheumatoid arthritis DISEASE
Depression DISEASE

Social History:
Patient is Jehovah's witness (okay with FFP plts cryo
albumin and any product that does not have RBC's). Denies ETOH
or recreational drug use. Smokes 1 pack per week.

Physical Exam:
Gen: NAD
Chest: CTA bilaterally no wheezes rales DISEASE or rhonchi
CV: RRR no murmurs rubs or gallops
Abd: Admission Date: [**2113-7-25**] Discharge Date: [**2113-7-31**]

Date of Birth: [**2030-11-26**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Acute mental status change

Major Surgical or Invasive Procedure:
Embolectomy [**2113-7-27**]


History of Present Illness:
Pt's a 82 yo F with h/o HTN DISEASE h/o of prox a-fib (not on
coumadin) mood disorder DISEASE on depakote (has had since CVA 4 yrs
prior) with prior L inferior division MCA infarct now
presenting with altered mental status. Pt basically at baseline
AA0x2 has been reclusive living alone with mood disorder DISEASE since
her stroke DISEASE - but has family heavily involved in her care -
including ex-husband who visits daily. Pt basically has been at
her baseline (which is described as more aggressive - usually
asking her family to leave within 10-15minutes of being around
her) but then 3-4 days ago noted being more lethargic - less
aggressive but without any other notable complaints per
ex-husband who saw pt then (no report of CP F/C HA SOB as
best assessed). Family getting concerned - were thinking would
be needing more higher level care placement as pt generally
weaker (no focal weaknesses) - but Sunday started appearing at
baseline again. Pt was seen Monday early and was doing well
(has called ex-husband roughly around 2pm and noted again at her
baseline) - however when home aide came by apartment today in
the morning - pt did not respond to door - found lethargic with
emesis/stool/urine around her. No further information able to
be obtained related to any events preceding to the evident n/v
bowel/stool incontinance.
Admission Date: [**2179-3-18**] Discharge Date: [**2179-3-24**]

Date of Birth: [**2105-12-17**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Heparin Agents

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
hypothermia sepsis DISEASE

Major Surgical or Invasive Procedure:
EGD
flex sig

History of Present Illness:
73yo F with PBC decompensated cirrhosis c/b encephalopathy DISEASE
ascites DISEASE and esoph varices who was discharged 2 days prior to
admission with AMS thought to be related to hepatic
encephalopathy DISEASE . At that time she was also found to have
hypoglycemia DISEASE PNA (tx w/ Azithro) and a UTI DISEASE (tx w/ Bactrim).
She was referred from clinic at [**Hospital Unit Name **] with chief
complaint DISEASE of BRBPR. She noted 2 painless BM's with BRBPR and
blood was noted on rectal exam without melena DISEASE . She denied any CP
or SOB but does note feeling weak. She does note some decreased
urine output lately as well as increased LE edema DISEASE and abdominal
distention. She notes abdominal 'fullness' DISEASE for the last few
weeks but denies nausea/vomiting. She notes some
lightheadedness DISEASE and thirst DISEASE while in the ED.
.
In the ED she was initially normotensive but was later found to
have SBP's in the 70's (baseline SBP in 90's). She was also
noted to be hypothermic with core temp of 93.4. Because of
concern for sepsis DISEASE an IJ was placed and she was placed on sepsis DISEASE
protocol. She was given Vanc/CTX/Flagyl and hydrocort and was
also noted to have worsening renal function with a Cr of 2.1
from NL baseline. Because of an initial potassium of 6.9 she
was given D50/insulin/kayexylate. She was admitted to the MICU
for further monitoring.

Past Medical History:
1. PBC cirrhosis DISEASE x 13 yrs known varices followed by Dr.[**Last Name (STitle) 497**]
2. Liver cirrhosis DISEASE
3. Hypothyroidism DISEASE
4. Osteopenia DISEASE
5. Status post cholecystectomy
6. History of ankle fractures DISEASE
7. Hypertension DISEASE

Social History:
Tobacco stopped 15 yrs ago 30 pack-yrs no alcohol or drug use
married with three children. Lives at home with husband


Family History:
No family history of strokes seizures DISEASE . Mother and father died
in 90s.

Physical Exam:
vitals (ED)- TAdmission Date: [**2179-3-31**] Discharge Date: [**2179-4-15**]

Date of Birth: [**2105-12-17**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Heparin Agents

Attending:[**First Name3 (LF) 943**]
Chief Complaint:
dizziness DISEASE x 1 day

Major Surgical or Invasive Procedure:
None


History of Present Illness:
73 yo F with h/o PBC decompensated cirrhosis DISEASE c/b
encephalopathy ascites DISEASE and esoph varices who presents with c/o
lightheadedness dizziness DISEASE x 1 day. Feels weak with decreased
energy level. Of note recently discharged on [**2179-3-24**] after
hypotensive/hypothermic episode w/ suspected sepsis DISEASE treated
empirically with a course of ceftriaxone flagyl and stress-dose
steroids. No infectious source was identified. Discharged to
home to complete prednisone taper.
.
In ED today found to be hypotensive DISEASE (SBP's in 80's) and
hypothermic (31 C rectal temp). EKG w/ bradycardia DISEASE to 40's. Plt
18. INR 1.5. given rewarming blankets. b/l EJ PIV placed. given
3L IVF's followed by peripheral dopa in ED. Recieved empiric
steroids w/ dex for Admission Date: [**2142-5-31**] Discharge Date: [**2142-6-8**]

Date of Birth: [**2070-2-24**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**2142-5-31**] Four Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending artery
with vein grafts to ramus intermedius obtuse marginal and PDA.


History of Present Illness:
This is a 72 year old with known coronary artery disease DISEASE . Over
the last several months he began to experience worsening chest
pain DISEASE and dyspnea DISEASE on exertion. He recently underwent stress
testng which was positive for ischemia DISEASE . Stress ECHO in [**Month (only) 216**]
[**2140**] was notable for an LVEF of 55-60%. Subsequent cardiac
catheterization on [**2142-5-11**] revealed severe three vessel coronary
artery disease DISEASE . Based upon the above results he was referred
for coronary surgical intervention.

Past Medical History:
Coronary Artery Disease DISEASE
History of PTCA(ramus) [**2128**]
History of Myocardial Infarction DISEASE [**2125**]
Diabetes Mellitus DISEASE Type II
Hypertension DISEASE
Hyperlipidemia DISEASE
History of Prostate Cancer DISEASE - s/p Radical Prostatectomy
Arthritis DISEASE
Gout DISEASE
Tonsillectomy


Social History:
Married with grown children. He is a very active volunteer. He
worked at the Mass Transit Authority prior to retiring/ Social
history is significant for the absence of current tobacco use
quit in [**2091**]. There is no history of alcohol abuse DISEASE and no
current alcohol use.


Family History:
There is no family history of premature coronary artery disease DISEASE
or sudden death. His father had CHF DISEASE in his 80s.


Physical Exam:
Vitals: BP 167/80 HR 56 RR 18
General: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple no JVD no carotid bruits DISEASE
Heart: regular rate normal s1s2 no murmur or rub
Lungs: clear bilaterally
Abdomen: soft nontender normoactive bowel sounds
Ext: warm no edema DISEASE no varicosities
Pulses: 2Admission Date: [**2150-6-19**] Discharge Date: [**2150-6-26**]

Date of Birth: [**2099-8-8**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
s/p Cardiac Arrest DISEASE

Major Surgical or Invasive Procedure:
Endotracheal intubation
ICD placement


History of Present Illness:
50F with hx of coronary vasospasm HTN DISEASE that presents from an OSH
after having suffered a cardiac arrest DISEASE in the field s/p CPR
with shock DISEASE x1.

Of note the pt was admitted to the [**Hospital1 1516**] service at [**Hospital1 18**] from
[**Date range (3) 1517**] after a month of increasing chest discomfort
concerning for coronary ischemia DISEASE . While hospitalized she had
dynamic ST depressions in V3-V6 during anginal episodes DISEASE and
elevated trop to 0.16. At that time workup included both cardiac
cath (X2) and CT of the coronary arteries. Cath suggested
isolated bilateral coronary ostial stenosis DISEASE . CTA was without
evidence of atherosclerosis DISEASE . At the time it was thought the pt
suffered from cardiac vasospasm DISEASE and not CAD. The pt was placed
on diltiazem Imdur and amlodipine. The pt followed up in
cardiology clinic [**5-25**] and at the time was feeling with only 2
lesss severe episodes of retrosternal chest pressure [**4-12**] that
occurred spontaneously without exertion lasting 10 min with
complete resolution. The pt had been able to participate in
aerobic exercise 45 minutes and endorsed 40lbs wt loss while on
Weight Watchers program. The pt was last seen by her PCP [**Last Name (NamePattern4) **]
[**2150-6-8**] Dr. [**Last Name (STitle) 1057**] at which time she was feeling well. At the
time she reported LE edema DISEASE since initiating amlodipine.

This morning the pt was bringing her children to school. Family
notes that patient has had increased chest discomfort this week
and using nitroglycerin at work. Her daughter notes chest pain DISEASE
this morning which resolved prior to taking her daughter to
school. EMS reports that arrived on scene with bystander CPR in
progress (approx 7:45). Arrest was confirmed. The pt was shocked
once. CPR was continued and on second analysis no shock DISEASE was
advised. At that time the pt was noted to move Amiodarone 150mg
was loaded and subsequently transferred to an OSH.

On arrival to the OSH (hx obtained by [**Hospital 1281**] Hospital ED
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1518**] via phone) initial vitals 108/55 HR 147
Wt 99.7kg. The pt was intubated (two attempts made). HR ranged
from 123 to 151 with SBPs 108/55 to 174/74. 140's to 150's.
Exam was notable for pt as unresponsive but was reaching for the
tube. She did not respond to commandy prior to being intubated
with Succinylcholine 150mg Versed 4mg Vecuronium 10mg and put
on a propofol gtt. No acute EKG changes. Wbc 20. ck/trop neg.
CXR/CT of chest shows large aspiration pneumonia DISEASE CT Head/CT
C-spine DISEASE unremarkable. The pt was given Ceftiaxone 1gm
Clindamycin 600mg Azithromycin 500mg. 18G. Small lac to back of
head- going to get some staples prior to transfer. Vitals prior
to transfer were HR 124 117/57.

In the CCU the patient is intubated. When propofol is weaned
patient moves all extremities however does not respond to
commands or follow directions.

On review of systems unable to be obtained from patient. Family
reports that she was in her usual state of health and went to
the beach this past weekend. Besides chest pain DISEASE episodes noted
above no other symptoms were reported by the patient. Family
notes patient to be a non reporter.

Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes (-)Dyslipidemia (-)HTN
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
h/o cholecystitis DISEASE s/p cholecystectomy


Social History:
Works in NICU at [**Hospital1 18**]
-Tobacco history: none
-ETOH: none
-Illicit drugs: none


Family History:
Paternal grandfather with MI at age 50. Father with
hypertension DISEASE .

Physical Exam:
Admission Labs
VS: 122/58 95 100%
GENERAL: Intubated Sedated
HEENT: NCAT. Sclera anicteric. PERRL. Laceration on back of head
with staples in place.
NECK: Supple with JVP at base of neck.
CARDIAC: PMI located in 5th intercostal space midclavicular
line. RR normal S1 S2. No m/r/g. No thrills lifts. No S3 or
S4.
LUNGS: No chest wall deformities scoliosis DISEASE or kyphosis DISEASE . Resp
were unlabored no accessory muscle use. CTAB no crackles
wheezes or rhonchi DISEASE .
ABDOMEN: Soft obese NTND. No HSM or tenderness DISEASE .
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis ulcers DISEASE scars or xanthomas DISEASE .
PULSES:
Right: Carotid 2Admission Date: [**2190-2-11**] Discharge Date: [**2190-2-24**]

Date of Birth: [**2132-12-15**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Dyspnea DISEASE


Major Surgical or Invasive Procedure:
Bronchoscopy

History of Present Illness:
57 yo F with PMHX of HTN DISEASE who presents with shortness of breath DISEASE x
7 days worsening over the last 3 days. Patient reports that she
has been feeling weak over the last 3 weeks with an
unintentional 10 lb weight loss DISEASE (of note over the last 2 months
she has lost 20lbs). 1 week ago she started feeling SOB with
exertion and Admission Date: [**2125-4-5**] Discharge Date: [**2125-4-12**]

Date of Birth: [**2072-2-15**] Sex: M

Service: Cardiac Surgery

HISTORY OF PRESENT ILLNESS: This is a 53-year-old gentleman
who went to see his primary care physician for his yearly
physical. At that time he reported a 1-year history of
burning substernal chest pain DISEASE with exertion. He underwent an
exercise treadmill test which was positive and subsequently
underwent cardiac catheterization which showed an ejection
fraction of 55% 90% left main coronary artery 90% proximal
left anterior descending artery 60% to 80% left circumflex
and a proximally occluded right coronary artery. The patient
was referred to Dr. [**Last Name (STitle) 1537**] for urgent coronary artery bypass
grafting.

PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia
3. Gastroesophageal reflux disease DISEASE .

ALLERGIES: No known drug allergies.

MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 mg by mouth once per day.
2. Lipitor 40 mg by mouth once per day.
3. Zantac 150 mg by mouth twice per day.

SOCIAL HISTORY: The patient lives at home with his wife and
his two children. He works in construction. Positive
tobacco with half a pack per day for 40 years.

BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
to [**Hospital1 69**] and taken to the
operating room on [**2125-4-6**] with Dr. [**Last Name (STitle) 1537**] for a coronary
artery bypass graft times three. Left internal mammary
artery to left anterior descending artery saphenous vein
graft to obtuse marginal and saphenous vein graft to
posterior descending artery. The patient had an intra-aortic
balloon pump placed in the Cardiac Catheterization Laboratory
due to his difficult anatomy and that remained during his
surgery.

The patient was transferred to the Intensive Care Unit in
stable condition on a Neo-Synephrine infusion.
Postoperatively the patient requried a moderate amount of
volume resuscitation.

Due to his elevated filling pressures and some minor
postoperative electrocardiogram changes a transesophageal
echocardiogram was performed at the bedside which showed a
normal ejection fraction with no wall motion abnormalities DISEASE .
The patient's hemodynamics improved over the next couple of
hours. On postoperative day one the patient was weaned and
extubated from mechanical ventilation. The intra-aortic
balloon pump was removed without difficulty. The
Neo-Synephrine was weaned to off.

On postoperative day two the patient was started on
Lopressor which he tolerated well. On postoperative day
three the patient's chest tubes were removed without
difficulty as well as his pacing wires.

On postoperative day four the patient's hematocrit was noted
to be down to 21. The patient was not symptomatic and had
stable vital signs. It was discussed with Dr. [**Last Name (STitle) 1537**] and a
transfusion was deferred.

On postoperative day five the patient continued to ambulate
with Physical Therapy.

On postoperative day six the patient's hematocrit was noted
to be down to 20.8. The decision was made to transfuse the
patientAdmission Date: [**2160-2-19**] Discharge Date: [**2160-2-24**]

Date of Birth: [**2095-10-21**] Sex: M

Service: EP SERVICE

CHIEF COMPLAINT: Syncope.

HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with
an extensive cardiac history including coronary artery
disease status post myocardial infarction DISEASE times two status
post multiple interventions congestive heart failure DISEASE with an
ejection fraction less than 20% ventricular tachycardia DISEASE
status post AICD placement in [**2157**] who presented to the
Emergency Department after syncopal DISEASE episodes and AICD firing.
The patient noted three days prior to admission feeling of
palpitations DISEASE especially when lying down for bed. On the day
of admission the patient became lightheaded a while bending
down to tie his shoes and felt some palpitations DISEASE . He then
felt a shock DISEASE from his ICD. He thereafter awoke on the
floor. Over the course of the day he had three more
episodes a feeling of palpitations DISEASE and lightheadedness DISEASE
followed by a shock DISEASE and then losing consciousness.

In the Emergency Department the patient was observed to have
an irregular wide complex tachycardia DISEASE consistent with atrial
fibrillation DISEASE in the setting of his underlying left bundle
branch block DISEASE . While in the Emergency Department he
developed transient regular wide complex tachycardia DISEASE to
approximately 170 beats per minute. His ICD fired during
this rhythm and was subsequently degenerated into a
ventricular fibrillation DISEASE prompting the ICD to fire again
recovering the rhythm back to atrial fibrillation DISEASE . An
amiodarone load was begun and the patient appeared to
spontaneously convert to sinus rhythm with left bundle branch
block. The ICD settings were increased while the patient was
in the Emergency Department so that the first shock DISEASE
administered was increased from 12 to 24 joules. The patient
was admitted to the Coronary Care Unit for continued
intravenous amiodarone loading and further evaluation.

PAST MEDICAL HISTORY: Coronary artery disease DISEASE status post
myocardial infarction DISEASE in [**2136**] and [**2150**]. He is status post
multiple percutaneous transluminal coronary angioplasty and
stents. Last catheterization on [**11/2159**] showed an ejection
fraction of 15% with anterolateral apical and inferior
akinesis. He had 2Admission Date: [**2160-12-25**] Discharge Date: [**2161-1-10**]

Date of Birth: [**2095-10-21**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with a
history of ischemic dilated cardiomyopathy DISEASE who presents with
five days of shortness of breath DISEASE . He developed the shortness DISEASE
of breath in the setting of cough lethargy DISEASE and subjective
fevers DISEASE . He presents to the Emergency Room where he was found
to be significant dyspneic. Physical examination revealed
evidence of pulmonary edema DISEASE and a chest x-ray showed
bilateral infiltrates. His oxygen saturation was 86% on room
air. His ABG was 7.54 48 27. He was given supplemental
oxygen and 60 mg of IV Lasix with a good response and his
oxygen saturation increased to 90% on three liters. He was
admitted to the cardiac floor with a diagnosis of a CHF DISEASE
exacerbation.

About one hour after arriving on the floor about five hours
after presentation he was found to be acutely hypoxic with
an oxygen saturation in the low 80's despite being on 100%
non rebreather. EKG showed possible inferior ST elevations
in the setting of a paced left bundle branch block DISEASE . He
continued to be hypoxic despite an additional 200 mg IV of
Lasix Heparin and a Nitro drip. For this reason he was
emergently intubated and transferred to the CCU.

On arrival to the CCU he was noted to have a temperature of
103.5. His heart rate was increased and his blood pressure
was low. His urine output dropped off. He was started on
Dopamine and his Nitro drip was stopped. He was also started
on Vanco Levo and Flagyl. As he defervesced his vital
signs stabilized and he began to have normal urine output
again.

PAST MEDICAL HISTORY: 1) Coronary artery disease DISEASE status post
anterior MI times two in [**2136**] in [**2145**] with an IMI in [**2150**].
Cath in [**2160-7-16**] revealed two vessel coronary artery
disease with a left ventricular apical aneurysm DISEASE . 2)
Congestive heart failure DISEASE with an EF of 20%. 3) Status post
AICD placement for monomorphic ventricular tachycardia DISEASE
upgraded in [**2160-2-14**]. 4) Atrial fibrillation DISEASE status post
ablation in [**2160-2-14**] currently on Amiodarone. 5)
Hypertension DISEASE . 6) Hypercholesterolemia DISEASE . 7) Chronic
obstructive pulmonary disease DISEASE . 8) Obstructive sleep apnea DISEASE on
bi-pap of 15 and 10 at home.

MEDICATIONS: Amiodarone 400 mg q day Lasix 120 mg q a.m.
Lipitor 20 mg q day Aspirin 81 mg q day Potassium Chloride
16 mEq q day Captopril 12.5 mg tid recently decreased from
25 mg tid Coreg 18.75 mg [**Hospital1 **] Xanax 0.25 mg tid
Multivitamin Vitamin E Coumadin 2.5 mg q day except for 5
mg on Tuesday and Saturday Zaroxolyn 2.5 mg po q week
Mirapex 0.125 mg q day.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: Works as a private investigator. Is
separated from his wife. [**Name (NI) **] a 55 pack year history of
smoking and quit in [**2155**]. Uses alcohol socially. Has no
history of drug abuse DISEASE .

PHYSICAL EXAMINATION: This is a 65-year-old man who was
intubated and sedated with a blood pressure of 93/42 on 5 of
Dopamine. Heart rate is 60 and he is satting 100% on 100%
FIO2. His HEENT exam is unremarkable. His neck is supple
with bounding carotid pulses. His chest is clear
anterolaterally. His heart is regular with no murmurs rubs
or gallops. His abdomen is benign. His extremities are
without edema DISEASE with 2Admission Date: [**2130-8-17**] Discharge Date: [**2130-8-21**]

Date of Birth: [**2079-11-23**] Sex: F

Service: [**Doctor First Name 147**]

Allergies DISEASE :
Penicillins / Bactrim

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Morbid obesity DISEASE

Major Surgical or Invasive Procedure:
1. Laparoscopic Roux en Y gastric bypass. ([**8-17**])
2. Laparoscopic cholecystectomy. ([**8-17**])
3. Takeback for Laparoscopic abdominal exploration. ([**8-18**])

History of Present Illness:
Mrs. [**Known lastname 1557**] is a 50 year old
woman with longstanding morbid obesity DISEASE refractory to non
operative attempts at weight loss DISEASE . She has a preoperative
weight of 230.7 pounds a height of 63 inches and a body mass
index of 40.9. She was evaluated by a multi-disciplinary
bariatric team and
deemed a suitable candidate for gastric bypass in accordance
with the National
Institute of Health Consensus Statement.


Past Medical History:
She suffers from associated comorbidities
including hypertension DISEASE non insulin dependent diabetes DISEASE
mellitus dyslipidemia cardiac disease DISEASE consisting of
diastolic dysfunction gastroesophageal reflux DISEASE non alcoholic
hepatitis cholelithiasis DISEASE urinary stress incontinence DISEASE
osteoarthritis DISEASE of the lower extremities and low back pain DISEASE .


Social History:
Socially she does not smoke although she has a 10-pack-year
history. She does not use drugs or drink excessive amounts of
alcohol. She is a nurse with a doctor at education and employed
at the [**State 1558**] in [**Hospital1 1559**]. She is married
and lives with her husband and two children.

Family History:
Her family history is noteworthy for heart disease arthritis DISEASE
obesity DISEASE and diabetes DISEASE .


Physical Exam:
On examination her recorded blood pressure is 142/82 with a
pulse of 82. She is alert and oriented and in no acute distress.

Pupils are equal round and reactive to light. Sclerae are
anicteric. Oropharynx is without lesions. There are no loose
teeth. Neck is supple without jugular venous distention bruits DISEASE

lymphadenopathy DISEASE thyromegaly or nodules. Trachea is in midline.

Lungs are clear to auscultation bilaterally. Heart is regular
with no murmurs rubs or gallops. Abdomen is obese soft
nontender and nondistended. There is no organomegaly DISEASE or masses.

There are no hernias DISEASE . Extremities have trace edema DISEASE bilaterally
with no evidence of venous stasis DISEASE or varices. There is no spine
or flank tenderness DISEASE . Neurologically cranial nerves II through
XII are intact and otherwise nonfocal.


Pertinent Results:
[**2130-8-17**] 10:14PM WBC-11.2*# RBC-4.18* HGB-11.7* HCT-35.0*
MCV-84 MCH-27.9 MCHC-33.4 RDW-13.4
[**2130-8-17**] 10:14PM NEUTS-86.5* BANDS-0 LYMPHS-10.2* MONOS-2.9
EOS-0.3 BASOS-0.1
[**2130-8-17**] 10:14PM GLUCOSE-167* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13

Brief Hospital Course:
Patient tolerated lap RYGBP and CCY and was transferred to PACU.
On night of POD0 patient was nauseous refractory to Zofran
Compazine and Phenergan. Subsequently her PCA was changed from
MSO4 to Dilaudid DISEASE and she was provided a Scopolamine patch. Later
in the night patient desat'ed to 79% on RA DISEASE with continued
nausea DISEASE . In AM of POD1 patient was transferred to T-SICU for
hypoxia DISEASE . CTA of chest was done and demonstrated no PE but
evidence of bilateral consolidation. CT abdomen demonstrated no
obvious leak. She was started on IV antibiotics for question
aspiration pneumonia DISEASE . After being seen by Dr. [**Last Name (STitle) **] in SICU
team decided to take patient back to OR for laparoscopic
exploration to rule out leak. No leak was found in OR. Patient
tolerated procedure well and was back in PACU. She was
transferred to floor without incident. Post-op course was
unremarkable thereafter. On [**8-19**] she was started on Stage I and
transitioned to Stage II later in the day. On day of discharge
patient did well on Stage III with good pain DISEASE control on oral
Roxicet. Patient was sent home with oral antibiotics for 10
days.

Discharge Medications:
1. Roxicet 5-325 mg/5 mL Solution Sig: [**1-20**] teaspoons PO every
4-6 hours as needed for pain DISEASE .
Disp:*250 ml* Refills:*0*
2. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day for 1
months.
Disp:*qs * Refills:*0*
3. Multi-Vitamins W/Iron Tablet Chewable Sig: One (1)
Tablet Chewable PO twice a day.
Disp:*60 Tablet Chewable(s)* Refills:*2*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days: Needs 10 total days of levo & flagyl.
Disp:*10 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days: Needs 10 total days of levo & flagyl.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Morbid obesity DISEASE s/p laparoscopic roux-en-y gastric bypass
Cholethiasis
Hypertension DISEASE
Non-insulin-dependent diabetes mellitus DISEASE
Dyslipidemia DISEASE


Discharge Condition:
Good

Discharge Instructions:
Please stay on stage 3 diet until follow-up. Do not
self-advance diet drink from a straw or chew gum. No heavy
lifting (Admission Date: [**2163-11-11**] Discharge Date: [**2163-11-20**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Right lung cancer DISEASE

Major Surgical or Invasive Procedure:
Bronchoscopy x3
PleurX catheter insertion
Emergent intubation


History of Present Illness:
This patient is an 83 year old female with small cell lung DISEASE
cancer DISEASE who was accepted in transfer from [**Hospital 1562**] Hospital.
Patient is with known right small cell lung cancer undergoing
chemotherapy/radiation therapy at [**Hospital3 1563**] [**Hospital3 **]. She
now presents with acute respiratory falure and is status-post
intubation. The reports from the outside hospital indicate
extrinsic compression from right mainstem bronchus obstructing
the proximal airway now with complete collapse of the right
hemithorax with partial collapse of the left hemithroax. CT
scans from [**Hospital1 1562**] indicate a large volume tumor DISEASE encasing the
right lung. The patient's family was advised of her dismal
prognosis and the patient was admitted for the possibility of a
meaningful intervention with the goal of palliative therapy.

Past Medical History:
End stage small cell lung canger with known brain metastasis DISEASE
Now s/p chemo/radiation therapy
Breast cancer DISEASE
X-Ray therapy pneumonitis DISEASE
COPD DISEASE
Osteoporosis DISEASE

Physical Exam:
T 98.4 HR 86 BP 108/45 RR 22 SpO2 95% on AC
0.45/450/14/PEEP5
Intubated sedated
RRR
CTA on the left minimal breath sounds on the right
Abdomen soft NT/ND DISEASE
Extremeties with 1Admission Date: [**2133-5-13**] Discharge Date: [**2133-5-15**]

Date of Birth: [**2088-3-11**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**Doctor First Name 1402**]
Chief Complaint:
palpitations DISEASE

Major Surgical or Invasive Procedure:
s/p DC - cardioversion on [**2133-5-14**]


History of Present Illness:
In brief 45 yo woman with history of SVT DISEASE (long R-P) followed
for 5 years episodes monthly usually lasting Admission Date: [**2109-11-13**] Discharge Date: [**2109-11-25**]

Date of Birth: [**2032-8-21**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Sulfonamides / Hytrin

Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 77 yo M with h/o CHF DISEASE c/o dyspnea DISEASE and 23lb wt.
gain in last 10 days. The patient was discharged from [**Hospital1 18**] 10
days ago. He has been followed closely by VNA and his
cardiolgoist. His lasix doses have been progressively increased
but his weight has been going up and he has been having
worsening SOB. Denies CP SOB fevers chills DISEASE .
.
In the ED initial vitals were 97.7 94 125/69 24 83%4L. O2 sat's
improved to the high 90's on NRB DISEASE . BNP Admission Date: [**2110-5-20**] Discharge Date: [**2110-6-3**]

Date of Birth: [**2032-8-21**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Sulfonamides / Hytrin

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Admission Date: [**2110-8-8**] Discharge Date: [**2110-8-12**]

Date of Birth: [**2032-8-21**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Sulfonamides / Hytrin / Sildenafil

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
1) leg ulcer DISEASE 2) SOB 3) abdominal pain DISEASE and nausea DISEASE

Major Surgical or Invasive Procedure:
[**8-10**] US guided RLQ paracentesis (4L)

History of Present Illness:
77 y/o man with PMH significant for severe right sided heart
failure pulmonary hypertension COPD DISEASE with interstitial lung DISEASE
disease and chronic kidney disease DISEASE who presents with 3 day hx
of ulcer DISEASE on his right leg pt denies trauma DISEASE to leg fevers DISEASE or
sweats. At baseline pt has mild pedal edema DISEASE and there was no
significant swelling DISEASE of the right leg. Pt has some baseline
erythema DISEASE of bil lower legs but noted moderate increased
erythema DISEASE around ulcer DISEASE and 'pus' which he described as yellow.

The patient is on home 02 around the clock and has been on 4L NC
for several months. Pt has had no recent changes in his
breathing at home and normally sats in the low 90s he denies
new SOB or dyspnea DISEASE . He has a chronic cough DISEASE which has not
changed recently. He sleeps on his side on 2 pillows and denies
PND. He has had no chest pain DISEASE . He denies hematemesis DISEASE at home.

In the ED he was satting 88% on 4L NC and then desaturated to
70s and was placed on a NRB DISEASE and satting 100%. He received
Prednisone 60mg for COPD DISEASE flair lasix 40mg IV x 1 and Vanco 1g
IV. He then developed some diffuse abdominal pain DISEASE and nausea DISEASE and
received zofran 4mg IV x2 and ativan 0.5mg x1.
ROS: Denies chest pain chills fevers DISEASE night sweats cough DISEASE
headache vision DISEASE changes diarrhea dysuria melena DISEASE or
hematochezia DISEASE . Has 2 pillow orthopnea DISEASE . Uses BiPAP at night.
Denies stroke TIA DISEASE DVT PE joint pains hemoptysis DISEASE . He does
report a chronic dry cough DISEASE which is at his baseline.


Past Medical History:
-- Hypertension DISEASE
-- Hyperlipidemia DISEASE
-- BPHAdmission Date: [**2151-5-21**] Discharge Date: [**2151-5-25**]

Date of Birth: [**2079-12-14**] Sex: F

Service: Medicine

HISTORY OF PRESENT ILLNESS: This is a 71-year-old woman with
a chief complaint DISEASE of hematemesis DISEASE .

The patient with a history of chronic obstructive pulmonary disease DISEASE and peptic ulcer disease DISEASE 40 years agoAdmission Date: [**2105-4-16**] Discharge Date: [**2105-4-27**]

Date of Birth: [**2044-3-8**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 2344**]
Chief Complaint:
Airway monitoring

Major Surgical or Invasive Procedure:
[**2105-4-24**]: Right video-assisted thoraoscopy with decortication


History of Present Illness:
61 year old female with PMHX of HTH presented with severe sore DISEASE
throat for 2 days rapidly getting worse associated with
difficulty swallowing liquids and neck pain DISEASE . Also found to have
fever DISEASE and tachycardia DISEASE . Unable to take meds only took BP meds
this am. Voice is hoarse DISEASE and descrbed as Admission Date: [**2158-5-3**] Discharge Date: [**2158-5-6**]

Date of Birth: [**2079-12-14**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Ativan / Valium / Haldol / Adhesive Tape / Sulfonamides /
Codeine / Morphine / Erythromycin/Sulfisoxazole / Amoxicillin

Attending:[**First Name3 (LF) 1650**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Pt is a 78 yo f with h/o COPD DISEASE with home O2 3L requirement CAD
s/p CABG in [**2140**] CHF DISEASE with EF 30% PVD DISEASE s/p aortofemoral bypass
RLL granuloma HL DISEASE and h/o dementia DISEASE who presents to the ED in
respitatory distress. Pt and son gave history in the [**Name (NI) **] that
that she became more SOB with increased o2 requirement (unknown
how much she increased it to). She came in to the hospital
tonight for SOB and reported some increase in her allergies DISEASE but
no fever DISEASE .

In the ED her vitals soon after arrival were HR 110s BP 194/79
RR30 o2 sat 94% on 8L face mask. She was found to be in obvious
respiratory distress DISEASE using accessory muscles tachypnic poor
air flow and speaking in one word sentences. She became
diaphoretic with CP and got 0.4mg of SL nitro with resolution of
chest pain DISEASE . She became tachy to 123 with RR 37 and BP 200/90
then was started on a nitro gtt at 2mg/kg/hr which was increased
to 3mg/kg/hr. At some point dropped her sats to 85%. She was
started on BiPAP with obvious improvement. Her CXR showed pulm
vascular congestion DISEASE . She was given 2mg IV magnesium solumedrol
125 IV x1 azithromycin 500mg for COPD DISEASE exacerbation. Her EKG
showed sinus tach with prominent p waves and LVH DISEASE as well as ST
elevation in v1 & v2 which was similar to prior. Cardiology was
consulted and said this is likely strain in the setting of
respiratory distress DISEASE . Exam notable for wheezes DISEASE poor air
movement and rhonci throughout. She received 20 IV lasix prior
to leaving the ED. Vitals at time of transfer were HR 101 BP
159/64 RR30 02 sat 100% on BiPap.

On the floor VS were BiPAP 8/8 Fio2 100 with afebrile RR 25 HR
99 BP 149/55. She was wearing the BiPAP but able to answer yes
and no to questions. Able to confirm history that last few days
had increased SOB non productive cough wheezing weakness DISEASE and
increased allergies DISEASE including nasal congestion runny nose DISEASE and
sinus pressure.

Review of systems:
(Admission Date: [**2148-1-22**] Discharge Date: [**2148-2-16**]

Date of Birth: [**2089-6-30**] Sex: M

Service: HEPATOBILIARY SURGERY

HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
male with a past medical history remarkable for pericarditis DISEASE
diverticulosis DISEASE status post colostomy and take-down
obstructive sleep apnea DISEASE who was evaluated for painless
jaundice DISEASE in [**2147-12-6**]. The patient's CT scan revealed
1.6 by 2.0 centimeter Klatskin tumor DISEASE with no evidence of
liver mass DISEASE nor encasement of vessels. The patient underwent
an endoscopic retrograde cholangiopancreatography which
showed normal pancreatic duct DISEASE but biliary stricture DISEASE
consistent with cholangiocarcinoma DISEASE . A stent was placed in
the upper third of the common bile duct. An MRCT in [**2147-12-6**] revealed a 2 centimeter mass in the porta hepatis
consistent with cholangiocarcinoma DISEASE with extensive periportal
lymphadenopathy DISEASE .

After a long discussion with the patient and family members
the patient was taken to the Operating Room on [**2148-1-22**].

PAST MEDICAL HISTORY: As noted above.

MEDICATIONS: None.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: Positive tobacco smoker for 25 years.

PHYSICAL EXAMINATION: At the time of discharge the patient
was well developed and well nourished in no apparent
distress. HEENT: Sclerae was icteric DISEASE with evidence of
jaundice DISEASE . Cranial nerves II through XII intact. Mucous
membranes were moistAdmission Date: [**2157-7-25**] Discharge Date: [**2157-7-28**]

Date of Birth: [**2110-12-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Codeine / Compazine / Zofran

Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
suicidal attempt

Major Surgical or Invasive Procedure:
none

History of Present Illness:
46 yo F with a history of depression DISEASE admitted after intentional
overdose DISEASE of benzodiazepines fluoxetine and phenytoin.
.
By verbal report at 8AM the patient ingested (based upon pill
bottles) an estimated 30 lorazepam 30 prozac 35 clonazepam 3
unisom and 4 dilantin. She was reportedly suicidal and her
husband had to break down the door to get to her. The patient
reports that she had depressed mood DISEASE for several months. She
recalls taking 'like a handful' of clonazepam fluoxetine and
phenytoin. She states that she has a great deal of stress at
home related to her children and husband and the only way to
deal with this difficulty is to 'leave this world.' She denies
ongoing thoughts of wanting to hurt herself.
.
In the ED 98.6 72 138/64 14 99% RA DISEASE . She developed hypotension DISEASE
with a single bp measurement of 80/50 pulse 62. She received
1.5L NS with improvement in the blood pressure back to Admission Date: [**2161-8-4**] Discharge Date: [**2161-8-7**]

Date of Birth: [**2110-12-29**] Sex: F

Service: SURGERY

Allergies DISEASE :
Codeine / Compazine / Vicodin

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p fall

Major Surgical or Invasive Procedure:
none

History of Present Illness:
50 y.o. F w/ h/o sucharachnoid cyst DISEASE & psychiatric DISEASE history who
presented s/p fall down a flight of stairs. She has a
questionable seizure DISEASE history and she is also on multiple
psychiatric DISEASE medications at home. In the ED she had altered
mental status and was intubated for airway protection.

Past Medical History:
Chronic hemorrhoids Hematuria Anemia DISEASE of chronic disease DISEASE GERD
Arachnoid cyst DISEASE fenestration w/ right craniotomy [**2157-2-22**]
Seizures DISEASE secondary to above Glaucoma DISEASE Asthma

PSHx: subarachnoid cyst DISEASE excision ([**2157**]) right cystoperitoneal
shunt ([**2161-6-9**])


Social History:
negative for tobacco or EtOH

Family History:
NC

Physical Exam:
ICU physical exam:

Gen: somnolent minimally responsive
CV: tachycardic regular rhythm
Pulm: CTAB
Abd: soft nontender nondistended
Ext: WWP no edema DISEASE

Exam on discharge:

VS: 98.3 73 126/65 20 94%RA
GEN: A&OX3 NAD
CHEST: CTAB RRR
ABD: Soft nontender nondistended
EXTR: L thigh with lg echymosis soft. LE warm pink and well
perfused. No edema DISEASE . Admission Date: [**2141-11-7**] Discharge Date: [**2141-11-13**]

Date of Birth: [**2091-11-1**] Sex: M

Service: GU

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Sharp abdominal pain DISEASE after cough DISEASE gross hematuria DISEASE

Major Surgical or Invasive Procedure:
s/p right partial nephrectomy on [**2141-10-24**]

History of Present Illness:
Pt is a 50 year old male who underwent a right partial
nephrectomy on [**2141-10-24**] and was discharged and presented to the
ER on [**2141-10-30**] after an MVA with complaint DISEASE of serosanguinous DISEASE
discharge from old chest tube site. Chest xray and ultrasound at
the time were negative. The patient then returned to hospital on
[**2141-11-7**] with a complaint DISEASE of severe abdominal pain DISEASE and one
episode of gross hematuria DISEASE after a cough DISEASE . The patient presented
to an outside hospital with a hematocrit of 27 and a BP of
70/40. The patient was given IV fluids and 1 unit of PRBC's
(post-transfusion hematocrit was 29) was stabilized and then
med flighted to [**Hospital1 18**].

Past Medical History:
IgA nephropathy DISEASE
Hypertension DISEASE
Gout DISEASE
Psoriasis DISEASE


Social History:
Patient has a significant alcohol history of [**7-11**] drinks/day

Family History:
Non-contributory

Physical Exam:
Gen: AAdmission Date: [**2189-2-5**] Discharge Date: [**2189-2-15**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
s/p collapse

Major Surgical or Invasive Procedure:
Intubation
Central venous line placement

History of Present Illness:
[**Age over 90 **] yo F hx IDDM HTN DISEASE who presented after she collapsed in the
lobby of her building while awaiting her son to pick her up for
appointment to see her PCP. [**Name10 (NameIs) **] was reportedly feeling well
recently according to son no infectious symptoms DISEASE . She came
down to the lobby and sat in a chair while waiting and then
collapsed. Pt had CPR initiated from bystanders (RN and aide in
lobby) per report EMS on presentation noted VFib was
defibrillated 200J x1. Review of provided strip appears to
demonsrate a NSR DISEASE with artifact followed by shock DISEASE and resumption
of NSR. FS was 188 unresponsive intubated in the field. Pt
hypotensive DISEASE to 60's on arrival to ED rec'd 1.5 L NS started on
levophed transiently. Pt had head chest/abd DISEASE CTs performed
which were unrevealing.


Past Medical History:
IDDM DISEASE c/b retinopathy neuropathy DISEASE
HTN DISEASE
H/O FRONTAL LOBE MENINGIOMA - RESECTED IN [**2124**]
S/P HEMORROIDECTOMY
S/P T AND A


Social History:
lives by herself independently no prior hx of tobacco.


Family History:
NC

Physical Exam:
VS: T 93.4 BP 156/60 HR 58 RR 16 O2 % on
Gen: elderly female sedated intubated unresponsive.
HEENT: Pupils 2mm nonreactive.
CV: RRR nl S1 S2 no m/r/g
Chest: breath sound b/l
Abd: soft ND no HSM
Ext: 2Admission Date: [**2131-9-6**] Discharge Date: [**2131-9-13**]

Date of Birth: [**2062-7-11**] Sex: M

Service: CSU


HISTORY OF PRESENT ILLNESS: Please note this is from
Cardiology's dictated pre catheterization admission note as
there was no history and physical examination from his
preoperative visit in the chart.

This is a 69-year-old male patient of Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
with a longstanding history of exertional angina DISEASE and abnormal
stress test now with worsening symptoms who was referred for
outpatient catheterization to [**Hospital1 188**]. He reports that for the past five to six years he
has been experiencing exertional back pain DISEASE until recently.
It occurred with activity such as walking and was resolved
with rest. Over the past two to three weeks he feels that
his symptoms have gotten worse. The pain DISEASE is now radiating to
his chest and seems to last for a longer period of time
requiring nitroglycerin for relief. He also reports having
dyspnea DISEASE after climbing hills. He does report occasionally
having symptoms at rest over the past few weeks for which he
takes nitroglycerin with relief. He states this occurs one
to two times per week on average.

PAST MEDICAL HISTORY:
1. Positive exercise tolerance test.
2. Hypertension DISEASE .
3. Hyperlipidemia DISEASE .
4. Occasional lightheadedness upon waking in the morning.
5. Duodenal ulcer DISEASE with melena DISEASE in [**2119**].
6. Thrombocytosis DISEASE .
7. Prostate cancerAdmission Date: [**2192-8-7**] Discharge Date: [**2192-8-21**]

Date of Birth: [**2130-11-19**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
left lower leg extremity ischemia DISEASE

Major Surgical or Invasive Procedure:
s/p Left femoral-below knee popliteal bypass


History of Present Illness:
This is a 61-year-old female who has a history
of a left femoral to above-knee popliteal bypass with
prosthetic due to a previous harvesting for CABG of her
saphenous vein. The patient also has a history of stenting
and angioplasty of the distal popliteal artery. The patient
presented to the hospital with increasing left foot pain DISEASE and
was found on angiography to have a completely thrombosed DISEASE
prosthetic graft. She had suitable runoff from the below-knee DISEASE
popliteal artery and the decision was made to perform a redo
bypass operation.


Past Medical History:
PVD (Fem stent [**6-12**])
B CEA
IDDM DISEASE
RAS
HTN DISEASE
CAD (MI '[**70**] CABGx3 DISEASE '[**71**])
CRI
Breast implants
Depression DISEASE

Social History:
80 pack year history quit in [**2170**]
no alcohol


Family History:
non contrib

Physical Exam:
On day of discharge patient was feeling well without
complaints vital signs stable. T 98.3 Pulse 74 BP 140/40 RR
18 O2 sats 96% RA DISEASE

The patient was not in any acute distress alert and oriented x
3 and not in any pain DISEASE .
CVS- regular rate and rhythm
Pulm- clear to auscultation bilaterally
Abd- non distended soft non tender
Wound- left leg- clean dry and intact
Pulses palpable bilaterally fem [**Doctor Last Name **] dp pt

Pertinent Results:
[**2192-8-17**] 03:40AM BLOOD WBC-15.0* RBC-3.22* Hgb-9.9* Hct-29.8*
MCV-93 MCH-30.6 MCHC-33.1 RDW-14.4 Plt Ct-495*
[**2192-8-7**] 07:45PM BLOOD Neuts-63 Bands-0 Lymphs-27 Monos-5 Eos-4
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2192-8-17**] 03:40AM BLOOD Plt Ct-495*
[**2192-8-17**] 03:40AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2*
[**2192-8-19**] 06:10AM BLOOD Glucose-118* UreaN-54* Creat-1.5* Na-136
K-4.0 Cl-100 HCO3-28 AnGap-12
[**2192-8-19**] 06:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.5

Blood culture all negative

Brief Hospital Course:
The patient was admitted on [**2192-8-7**] for a left lower extremity
bypass on [**2192-8-8**]. The patient underwent a left fem-bk [**Doctor Last Name **] with
right arm vein (cephalic Admission Date: [**2140-11-16**] Discharge Date: [**2140-11-24**]

Date of Birth: [**2080-4-23**] Sex: M


CHIEF COMPLAINT: Cough/shortness of breath.

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1726**] is a 60-year-old male
with a past medical history significant for hypertension DISEASE
times two who developed a dry cough DISEASE in late [**Month (only) **] while
fly fishing in [**State 1727**]. The cough DISEASE persisted and he was given
erythromycin times ten days times two courses by his primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1728**]. The erythromycin did not improve
the patient's symptoms.

The patient describes the cough DISEASE as dry DISEASE not worse at night
breath. He denied fevers DISEASE and chills. He states that he
lost about six pounds over the past two months intentionally.
Over the past one to two weeks however he has noted
increasing dyspnea DISEASE with stairs as well as fatigue DISEASE . On the
day prior to admission he started a Z pack.

At his primary care physician's office today he had a chest
x-ray which disclosed an enlarged heart and interstitial
infiltrates. An esophagogastroduodenoscopy was done as well
as an echocardiogram which disclosed evidence of a
pericardial effusion DISEASE with tamponade DISEASE .

There was diastolic collapse of the right atrium and right
ventricle. The patient was sent to the Emergency Department
at [**Hospital6 256**] for evaluation of the
pericardial effusion DISEASE and drainage. His pulses paradoxes was
18. The echocardiogram performed in the Emergency Department
was consistent with cardiac tamponade DISEASE . The patient remained
hemodynamically stable.

PAST MEDICAL HISTORY:
1. Melanoma. Patient is status post removal of melanoma DISEASE in
[**2118**] and in [**2138**].
2. Empyema of the left lung in [**2122**].
3. Labile hypertension DISEASE .
4. Overweight.
5. Hypercholesterolemia DISEASE .
6. Myxomatous mitral valve prolapse DISEASE with mild mitral
regurgitation.
7. Non-sustained ventricular tachycardia DISEASE .
8. Chronic asymptomatic VEA.
9. Peripheral vision loss DISEASE .
10. History of smoking quit in [**2122**].

MEDICATIONS:
1. Tenormin 150 mg q.d.
2. Lipitor 80 hs.
3. Enteric coated aspirin 325 mg po q.d.
4. Accupril 20 mg po q.d.
5. Multivitamin.
6. Folate 2 tablets b.i.d.
7. Vitamin E.
8. Vitamin B6.
9. Vitamin B12.
10. Ativan prn sleep.

ALLERGIES: Penicillin. Patient has a rash DISEASE .

SOCIAL HISTORY: Patient does office work. He has been a
widow for the past nine years. He coaches a girls basketball
team. He has two children ages 30 and 25. He lives with
his 30-year-old daughter. [**Name (NI) **] has a 2-year-old grandchild.
He smoked cigars until [**2122**]. He has not had alcohol for the
past nine years.

FAMILY HISTORY: No heart disease DISEASE and no diabetes mellitus DISEASE .

REVIEW OF SYSTEMS: No fevers chills DISEASE or night sweats.
Patient reports a six pound intentional weight loss DISEASE over the
past two months. No history of positive PPD or Tuberculosis DISEASE
exposure. No upper respiratory infection symptoms with
cough DISEASE . No nausea vomiting diarrhea DISEASE or abdominal pain DISEASE but
occasionally Admission Date: [**2141-1-4**] Discharge Date:[**2141-1-12**]

Date of Birth: [**2080-4-23**] Sex: M

Service:Oncology
CHIEF COMPLAINT: Short of breath times one week plus
weakness.

HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male with a history of metastatic lung cancer DISEASE to brain
failure to thrive. He had a recent diagnosis on [**11-5**] of
lung adenocarcinoma DISEASE with metastases to [**Last Name (LF) 500**] [**First Name3 (LF) **]
pericardium. He had a recent admit for malignant pericardial
effusion with tamponade DISEASE status post drainage on [**11-5**]. Plan
for chemotherapy after patient completes XRT. Had an Lumbar
puncture on [**11-29**] with negative meningeal spread of cancer DISEASE .
He has noted one week prior to admission progressive increase
He had a pulses paradoxus of 15 in the emergency department.
No fever chills chest pain cough nausea vomiting DISEASE
diarrhea abdominal pain DISEASE . He had a normal p.o. intake but
decreased ambulation secondary to weakness post XRT. Can go
approximately 10 steps and then gets tired with short of
breath.

In the emergency department he got a dose of Levofloxacin for
concern of pneumonia DISEASE and bronchitis DISEASE and stress dose steroids.

Chest x-ray shows increased in cardiac silhouette.
Electrocardiogram showed alternans. Bedside echo concerning
for tamponade DISEASE . Catheterization laboratory for pericardial
drain placement. Got 2500 cc's removed.

PAST MEDICAL HISTORY: Significant for hypertension DISEASE
hypercholesterolemia mitral valve prolapse DISEASE status post
melanoma DISEASE . Status post resection in [**2118**] and [**2138**]. Empyema
left lung [**2122**] status post thoracotomy and supraventricular DISEASE
tachycardia DISEASE . Lung adenocarcinoma with metastases to brain
[**Year (4 digits) 500**] pericardium. Now undergoing brain XRT. Atrial
flutter peripheral visual loss DISEASE .

An echo on [**11/2134**] showed EF greater than 55%

MEDICATIONS ON ADMISSION:
1. Decadron 4 mg q AM 2 mg q PM.
2. Zantac 150 mg b.i.d.
3. Sotalol 80 mg twice a day.
4. Ambien 10 mg q h.s.
5. Lipitor 80 mg q h.s.
6. Folate 1 mg q day.
7. Accupril 10 mg q day.
8. ASA 81 mg q day.

ALLERGIES: Penicillin which causes a rash DISEASE .

SOCIAL HISTORY: Lives with a daughter at home. No tobacco
in the past 20 years no alcohol.

PHYSICAL EXAMINATION: On admission in general no acute
distress pleasant slightly tachypneic. Vital signs 97.5
heart rate 94 blood pressure 99/61. Respiratory rate 36
99% on 100% face mask. Left pupil minimally reactive down
visual acuity. OP clear. Neck: No jugular venous
distention. Pulmonary: Coronary artery disease DISEASE bilaterally.
Carotids: Regular rate and rhythm. No murmurs. Abdomen:
Soft nontender no distension. Bowel sounds positive.
Extremities: No cyanosis clubbing DISEASE or edema DISEASE . 2Admission Date: [**2198-4-23**] Discharge Date: [**2198-5-8**]

Date of Birth: [**2122-10-14**] Sex: M

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
fever DISEASE

Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Pancreatic debridement with wide drainage.
3. Open cholecystectomy.
4. Placement of a combined G/J tube (MIC tube).
5. PICC line placement
6. ERCP with stent


History of Present Illness:
This is a 75 year old man who is a retired anethesiologist with
h/o CAD s/p CABG and ischemic cardiomyopathy DISEASE with EF of 25% who
was recently discharged from [**Hospital1 18**] following a hospital course
for gallstone pancreatitis DISEASE and now re-presents from rehab for
fevers DISEASE . During last admission he was transferred from OSH with
with fever DISEASE and pancreatitis DISEASE which was thought to be from
gallstones DISEASE although there were no gallstones DISEASE in the bile ducts
just in the gallbladder itself. CT scan done on admissionw as
consistent with severe pancreatitis DISEASE . ERCP was done on [**2198-4-6**]
with sphinceterotomy and CBD stent placed. His post procedure
course was complicated by fevers DISEASE and repeat CT abd shows
progression of severe pancreatitis DISEASE with extensive
peripancreatitis fluid collection. This was thought to be
either from PNA or from inflammation DISEASE from his pancreatitis DISEASE . He
finished a course of azithro/ctx and a course of flagyl/cipro
and eventually he devefesced. All cultures were negative. He
was discharged to rehab.
.
At rehab he reports having fevers DISEASE since Friday [**2198-4-21**] with
highest at 102.0. He has no localizing pain DISEASE . Denies cough
dysuria DISEASE abd pain DISEASE or nausea DISEASE and vomit DISEASE .
.
ROS: Negative for headache DISEASE chest pain shortness DISEASE of breath or
change in bowel habits.

Past Medical History:
# Coronary artery disease DISEASE status post CABG x4 in [**2183**].
# Status post MI in [**2182**].
# Ischemic cardiomyopathy DISEASE EF 20-25% echo [**2194**].
# Atrial flutter DISEASE currently A-paced.
# Ventricular irritability DISEASE .
# ICD placement [**2193**] changed in [**2195**] ([**Company 1543**] dual- chamber
system.)
# CRI with a baseline creatinine of 1.2-1.5.
# Gout DISEASE .
# Gallstones DISEASE .
# Kidney stones DISEASE .
# h/o Syncope DISEASE .

Social History:
A retired anesthesiologist worked in pain DISEASE management. Denies
tobacco drugs. Bottle of wine per week.

Family History:
Father had a MI at age 70.

Physical Exam:
VITALS: 102.2 112/P 68 16 93%-RA
GEN: AAdmission Date: [**2141-1-4**] Discharge Date: [**2141-1-12**]

Date of Birth: [**2080-4-23**] Sex: M

Service:Oncology
DISCHARGE DIAGNOSES:
1. Non-small cell lung carcinoma DISEASE metastatic to [**Last Name (LF) 500**] [**First Name3 (LF) **]
and pericardium.
2. Pericardial tamponade DISEASE requiring pericardiocentesis DISEASE .
3. Hypoxia due to multifactorial lung disease DISEASE .
DISCHARGE MEDICATIONS:
1. Ambien 10 mg p.o. q.h.s.
2. Sotalol 80 mg p.o. b.i.d.
3. Multivitamin one p.o. q.d.
4. Tylenol 225 to 650 mg p.o. q. four to six hours p.r.n.
5. Colace 100 mg p.o. b.i.d.
6. Protonix 40 mg p.o. q.d.
8. Morphine Sulfate 1 to 5 mg IV q. four to six hours p.r.n.
9. Dibutoline one application TP q.i.d. p.r.n.
10. Methylprednisone 80 mg p.o. b.i.d..
11. Albuterol nebs q. four to six hours.
12. Atrovent nebs q. four to six hours.
13. Levofloxacin 500 mg p.o. q.d. till [**2141-1-19**].
13. Bactrim Double Strength tabs one p.o. b.i.d. till
[**2141-1-19**].
14. Percocet one to two tabs p.o. q. four to six hours p.r.n.

He was discharged to [**Hospital 1739**] Hospice in stable condition.
He is DNI DNR and moving towards comfort care only.




[**Known firstname **] [**Last Name (NamePattern4) 1735**] m.d. [**MD Number(1) 1736**]

Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36

D: [**2141-1-11**] 10:20
T: [**2141-1-11**] 10:15
JOB#: [**Job Number 1740**]
Admission Date: [**2181-9-5**] Discharge Date: [**2181-9-14**]


Service: CARDIAC

HISTORY OF THE PRESENT ILLNESS: The patient is an
82-year-old female with hypercholesterolemia DISEASE chronic renal
insufficiency hypertension DISEASE and long history of atypical
chest pain DISEASE as well as possibly asymptomatic myocardial
infarction DISEASE a long time ago. Prior to admission the last
cardiac evaluation was in [**Month (only) 956**] when a stress MIBI showed
an ejection fraction of 67% without evidence of ischemia DISEASE
although the patient only tolerated three minutes.

The patient was in the usual state of health until several
months ago when she began to complain of increased shortness DISEASE
of breath and pedal edema DISEASE . The symptoms specifically
shortness of breath and chest pain DISEASE increased in intensity
about two weeks prior to admission. On [**2181-9-3**] the
patient presented to her primary care physician and stress
tests were performed. On the night prior to admission the
patient presented with left sided substernal chest pain DISEASE
radiating to the scapula that had lasted for 10 to 12 hours.
The patient lasted all night prior to admission without
significant relief from sublingual nitroglycerin. The
patient complained of nausea shortness DISEASE of breath. The
patient was not diaphoretic. EKG performed at the time
showed ST elevations in leads V1 through V3 and loss of R
wave. The patient was given Morphine nitropaste and aspirin
according to protocol.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE .
2. Hypercholesterolemia DISEASE .
3. Gout.
4. Arthritis.
5. Multinodular goiter DISEASE .
6. History of appendectomy.
7. Possible history of myocardial infarction DISEASE in distant
past.

ALLERGIES: The patient is allergic DISEASE to AMIODARONE WHICH
CAUSES FACIAL EDEMA.

MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg PO q.d.
2. Diltiazem CD 180 PO q.d.
3. Hydrochlorothiazide 25 q.d.
4. Lipitor 10 mg PO q.d.
5. Lopressor 25 mg PO b.i.d.
6. Nitroglycerin patch 10 mg PO q.d.
7. Vasotec 75 mg PO b.i.d.
8. Allopurinol 100 mg q.d.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION: Examination revealed the following:
Vital signs afebrile. Heart rate: Admission Date: [**2200-6-2**] Discharge Date:[**2200-7-8**]

Date of Birth: [**2131-8-1**] Sex: F

Service:

DATE OF DISCHARGE: Pending.

AGE: 68.

HISTORY OF THE PRESENT ILLNESS: [**Known firstname 1743**] [**Last Name (NamePattern1) 1744**] is a
68-year-old female who was at acute rehabilitation at
[**Location (un) 38**] after having a right-sided knee replacement on
[**2200-5-6**]. The patient had been on antibiotics following her
knee replacement and had developed abdominal pain DISEASE two weeks
prior to admission with diarrhea DISEASE . The patient was presumed
to have C. difficile DISEASE and had been started on Flagyl. She was
taken to the [**Hospital1 69**] Emergency
Department and on presentation she had a white blood cell
count of 25000 large amounts of nausea DISEASE and fevers DISEASE up to
101.0 degrees. Of note the patient had been on Flagyl since
[**5-21**] until the patient's presentation on [**2200-6-2**].

REVIEW OF SYSTEMS: Review of systems was negative for
dysuria DISEASE .

PAST MEDICAL HISTORY: History was notable for the following:
1. Osteoarthritis.
2. Left sided breast cancer DISEASE .
3. Diverticulitis.
4. Gastrointestinal bleed.
5. Fibromyalgia.

MEDICATIONS ON ADMISSION:
1. Coumadin.
2. Vistaril.
3. ....................
4. Tamoxifen.
5. Zoloft.
6. Protonix.
7. Ditropan.
8. [**Doctor First Name **].
9. Lasix.

ALLERGIES: The patient is allergic DISEASE to SULFA AND IBUPROFEN.

SOCIAL HISTORY: The patient has no history of alcohol
drugs or smoking.

PHYSICAL EXAMINATION: On presentation the patient's
physical examination revealed the following: Temperature
100.3 heart rate 109 blood pressure 149/74 respiratory
rate 18 oxygen saturation 97%. She was ill-appearing on
presentation with a diffusely tender abdomen with positive
rebound and no guarding. Stool was guaiac negative.

HOSPITAL COURSE: The patient was then admitted medical
service initially for management of her presumed C. difficile DISEASE
colitis DISEASE .

The patient was admitted to the medical service
postoperatively and then was noted to have pleural effusion DISEASE
and then underwent a thoracocentesis of her effusion. On the
14th the patient continued to have poor hospital course and
on [**2200-6-5**] due to difficult medical management of the
disease surgical consultation was obtained and the patient
underwent a subtotal colectomy with ileostomy.

Regarding the patient's operation please referred to
Dr. [**Name (NI) 1745**] operative note on [**2200-6-5**]. Postoperatively
the patient was taken to the Medical Intensive Care Unit for
further management of her disease. She underwent numerous
transfusion of fresh-frozen plasma. The patient was
continued to be intubated. The patient was managed in the
Medical Intensive Care Unit with bilateral chest tubes placed
while the patient was in the Medical Intensive Care Unit.
The patient continued to have high fevers DISEASE . Sputum culture
from [**2200-6-21**] demonstrated Methicillin-resistant DISEASE
Staphylococcus aureus and transthoracic cardiac
echocardiogram demonstrated no pericardial effusion DISEASE or no
obvious vegetations DISEASE while the patient continued to have
these fevers DISEASE . The patient was continued on Vancomycin and
continued to be intubated for a long period of time until
[**2200-6-25**] when the patient was extubated successfully.

Post extubation the patient had difficulty with her voice
and swallowing and she was deemed an aspiration risk so
Dobbhoff was placed. She was then transferred to the floor
and she continued to do well. Chest tubes were removed and
she stopped having fevers DISEASE . Physical therapy consultation was
obtained and the patient began to improved dramatically while
on the floor. She remained afebrile with stable vital signs
with reasonable respiratory parameters and she was continued
on tube feeds or Promote with fiber at a goal rate of 70 cc
per hour.

The patient will be discharged to a rehabilitation facility
on the following regimen:
1. Lopressor 50 mg PO t.i.d.
2. Ambien 10 mg PO q.h.s.
3. Vancomycin 1 gram q.d.
4. Heparin 5000 units subcutaneously b.i.d.
5. Regular insulin sliding scale.
6. Protonix 40 mg IV q.d.
7. The patient will continue on her tube feeds Promote with
fiber at 70 cc an hour.

FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 519**] in
one to two weeks. The patient will followup with her primary
care physician at the time deemed appropriate by their
office.

OF NOTE: Portions of this chart were not available during
this dictation.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] M.D. [**MD Number(1) 521**]

Dictated By:[**Name8 (MD) 522**]
MEDQUIST36

D: [**2200-7-7**] 13:37
T: [**2200-7-7**] 13:57
JOB#: [**Job Number 1746**]
Admission Date: [**2174-8-8**] Discharge Date: [**2174-8-17**]


Service: [**Location (un) 259**] MEDICINE

HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
woman a resident of [**Hospital3 **] Facility with
end-stage dementia diabetes mellitus DISEASE and multiple other
medical problems who presented to [**Hospital6 649**] with a history of lethargy cough fever DISEASE and
shortness of breath DISEASE .

According to the [**Hospital 228**] [**Hospital3 **] chart the
patient had several recurrent temperatures to 101Admission Date: [**2175-5-3**] Discharge Date: [**2175-5-23**]


Service: MEDICAL ICU

HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1764**] is an 80 year-old
female with a past medical history significant for dementia DISEASE
presents as a transfer from HCRA with fevers DISEASE and hypotension DISEASE .
Per available information the patient was in her usual state
of health until 9:30 in the morning of [**2175-5-3**] when she
spiked a temperature to 104. She was seen by [**Name6 (MD) 1765**] cover MD
and found to be bradycardic. A few hours later the patient
was found to be hypotensive DISEASE with a systolic blood pressure in
the 50s. She was unresponsive. She was bolused 500 cc of
normal saline without a change in blood pressure and was
transferred to the [**Hospital1 69**]
Emergency Department at that point.

Initial vital signs in the Emergency Room were temperature
100.8. Blood pressure 54/27 with a pulse of 88.
Respirations 28 with an O2 saturation of 91% on room air
increasing to 99% on 10 liters. She received 4 liters of
intravenous fluids antibiotics were started Ampicillin
Gentamycin and Flagyl and a left subclavian triple lumen
catheter was placed. Physical examination was
noncontributory initially. Initial laboratories were notable
for a white blood cell count of 10.9 with a bandemia DISEASE .
Urinalysis was very concentrated and multiple white blood
cells. Despite intravenous fluids systolic blood pressure
remained low and she was started on a dopamine drip titrated
to 15 mcs per minute and systolic blood pressure was
maintained in the low 100s. At that point the patient was
transferred to the MICU for further evaluation.

PAST MEDICAL HISTORY: 1. Dementia. 2. Hypertension. 3.
Glaucoma DISEASE . 4. Coronary artery disease DISEASE . 5. Ischemic
cardiomyopathy DISEASE with EF of 40%. 6. PEG tube. 7. Paroxysmal
atrial fibrillation DISEASE on Amiodarone. 8. Type 2 diabetes DISEASE .

MEDICATIONS ON TRANSFER: Sorbitol 30 mg po q day Amiodarone
200 mg po q day vitamin C 500 units po q day aspirin 81 mg
po q day multivitamin q day Axid 150 mg po q day Risperdal
10 mg po b.i.d. and zinc 220 mg po q day.

PHYSICAL EXAMINATION: Afebrile 97.9. Heart rate 99. Blood
pressure 84/43. O2 sat 99% on nonrebreather. Generally was
unresponsive to oral stimuli or to sternal rub. Of notethe
patient is Russian speaking only. HEENT pupils are equal
round and reactive to light and accommodation. Extraocular
movements intact. Neck was supple without lymphadenopathy DISEASE .
Neck veins were flat. Chest was clear to auscultation
bilaterally. Heart was tachycardic with distant heart
sounds 2/6 systolic murmur at the left lower sternal border.
Abdomen soft nontender nondistended. Normoactive bowel
sounds. Extremities mild pedal edema DISEASE .

LABORATORY: White blood cell count 10.9 hematocrit 34.4
platelet count of 214 INR 2.0 sodium 147 creatinine 2.0
anion gap of 14. Her differential showed 62 polys and 20
bands. Urinalysis was cloudy specific gravity of 1.015 pH
of 8.5 large blood positive nitrite greater then 300
protein large leukocyte esterase greater then 50 white
blood cells and red blood cells with many bacteria. Chest
x-ray showed diffuse left sided infiltrates.
Electrocardiogram was sinus at 100 with normal axis and
intervals Admission Date: [**2151-7-16**] Discharge Date: [**2151-8-4**]



HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
African American female who on the morning of [**7-16**] was
found on the floor of her unair-conditioned home by a
relative during the heat wave. She was conscious but
The family reports she had not been drinking much and had not
been feeling well one day prior to admission. The family
also reports a productive cough DISEASE 30 lb weight loss DISEASE in the
last three months shortness of breath DISEASE over the last few
months worsened by exertion and increasing edema DISEASE .

The patient was taken to the Emergency Department and rectal
and irregular. Blood pressure was 137/76 respiratory rate 27.
Cooling measures were started in the Emergency Department.
She was placed on a 100% oxygen nonrebreather mask. The
patient gradually became alert and oriented times two. In
the Emergency Department she subsequently became hypotensive DISEASE
with blood pressure of 80/49 heart rate 87 and irregular.
More aggressive fluid resuscitation was started. She was
briefly placed on a Norepinephrine drip for hemodynamic
instability which was later changed to a Levophed drip. A
central line was placed. The patient's temperature gradually
came down to 98.6 over several hours. Laboratory studies and
blood cultures were drawn. Chest x-ray was done.
Electrocardiogram urinalysis arterial blood gases were doneand
the patient was started on broad spectrum antibiotics.

PAST MEDICAL HISTORY: Cardiomyopathy- idiopathic DISEASE echocardiogram
in [**2141**] showed an ejection fraction of 20%. Hypertension DISEASE .
Pulmonary hypertension DISEASE . Chronic atrial fibrillation DISEASE . Intermittent
left bundle branch block DISEASE . History of anemia DISEASE and heme positive
stools (previously refused colonoscopy). History of previous
pulmonary embolism DISEASE in [**2141**]. History of previous stroke DISEASE in [**2141**].
History of previous myocardial infarction DISEASE (undocumented in
[**2144**]). Chronic right-sided pleural effusion DISEASE first found in
[**2150-11-12**]. History of multiple episodes of cellulitis DISEASE .
Claustrophobia.

MEDICATIONS ON ADMISSION: Coumadin 6 mg alternating 4 mg
q.d. Lasix 20 mg q.d. Lisinopril 10 mg q.d. Diltiazem 300
mg q.d. Digoxin 0.125 mg q.d.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: The patient is an African American female
who lived alone. Family checks on her often and lives
nearby.

FAMILY HISTORY: There is a family history of colon cancer DISEASE .

PHYSICAL EXAMINATION: On physical examination (as noted in
Emergency Department/Medicine Intensive Care Unit notes).
General a thin malnourished African American female
disoriented. Head eyes ears nose and throat pupils are
equal round and reactive to light extraocular movements DISEASE
intact. Dry mucous membranes. Oropharynx clear. Neck
supple. Jugulovenous distension noted to be 6 cm. Lungs
bibasilar DISEASE crackles denies cough DISEASE . Rhonchi throughout. No
wheezes. Cardiovascular irregularly irregular rhythm
II/VI systolic murmur DISEASE . Abdominal positive bowel sounds
soft nontender nondistended no rebound or guarding. No
masses. Guaiac positive rectal examination. Extremities
no edema DISEASE severe chronic venous insufficiency/stasis
dermatitis DISEASE in the lower extremities 1Admission Date: [**2169-3-26**] Discharge Date: [**2169-4-9**]

Date of Birth: [**2090-12-5**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Right foot pain DISEASE s/p stenting of right superficial femoral artery


Major Surgical or Invasive Procedure:
[**2169-3-30**] stenting of right superficial femoral artery


History of Present Illness:
78 y.o female s/p angio of the SFA with stent on [**2169-3-14**]
presents with RLE foot pain DISEASE

Past Medical History:
Adrenal insufficiency DISEASE
hx hypercaoguable state - but no clear h/o DVT/PE DISEASE
hypercholestremia DISEASE
Admission Date: [**2169-4-16**] Discharge Date: [**2169-4-25**]

Date of Birth: [**2090-12-5**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
78 yo F w/ abd pain DISEASE

Major Surgical or Invasive Procedure:
right femoral line
right upper extremity PICC
transient levophed


History of Present Illness:
78 yo F w/ h/o hyperchol IDDM asthma DISEASE and s/p CCY several
years ago who presents from rehab w/ c/o RUQ abd pain DISEASE x 3 days.
Patient d/c from [**Hospital1 18**] [**2169-4-14**] following a right transmetatarsal
amputation for gangrenous DISEASE right foot. Patient's admission was
uncomplicated other than a fever DISEASE spike on POD #1 o/n but CXR
negative and patient defervesced. She required 1 U PRBC
intraoperatively for hct 26.8. Per daughter patient is somewhat
confused and currently an unreliable historian thus I relied on
her daughter for hx. Her daughter states that her mom first
started c/o diffuse abdominal pain DISEASE but particularly subxiphoidal
abdominal pain DISEASE on Friday. Her mother states that the pain DISEASE was
occasionally worse w/ eating but her daughter states that her
mom was eating a full liquid diet. She has been vomiting DISEASE
however. Occasionally it is the food she just ate and other
times she will vomit DISEASE up her pills. However she had soup and
jello this am w/o vomiting DISEASE . Her mom has also been c/o back pain DISEASE
but as far as her daughter can tell this is just her chronic
LBP DISEASE . She doesn't seem to relate the pain DISEASE to her abdominal pain DISEASE .
Patient's daughter thinks her mom's last BM was on Friday but
she is really not sure. Per notes patient spiked temp of 101 at
rehab. Patient's daughter is not aware of any h/o PUD DISEASE or CAD in
her mother. [**Name (NI) **] mom did have a gall bladder DISEASE attack severeal
years ago leading to CCY but o/w no abdominal surgeries/issues.
Admission Date: [**2169-5-2**] Discharge Date: [**2169-5-10**]

Date of Birth: [**2090-12-5**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fever DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
pt is a 78 yo Spanish-speaking lady who presents w/ fevers DISEASE and
lethargy DISEASE . She is s/p was admit at [**Hospital1 18**] [**Date range (2) 1799**] c/b
adrenal insufficiency DISEASE (cortisol 1.1) bilateral adrenal masses
urosepsis DISEASE . She was briefly on pressors and was noted to have a R
MTA cellulitis DISEASE as well. She is s/p right transmetatarsal
amputation [**3-25**] by [**Month/Year (2) 1106**] surgery and is planned for elective
R BKA once her medical condition stabalizes. On day of this
admission pt was noted to have fevers DISEASE and lethargy DISEASE at her
rehab was Admission Date: [**2149-6-2**] Discharge Date: [**2149-6-5**]

Date of Birth: [**2081-3-23**] Sex: M

Service:

CHIEF COMPLAINT: Left lower lobe pneumococcal pneumonia DISEASE
congestive heart failure DISEASE .

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1968**] is a 68-year-old white
male with a history of CAD status post three vessel CABG EF
less than 20% mild COPD hypertension DISEASE history of head and
neck cancer DISEASE history of Hodgkin's disease DISEASE status post
resection in [**2144**] in remission who presents with left sided
chest pain DISEASE worsening dyspnea DISEASE on exertion shortness of
breath and cough DISEASE . Roughly two months ago the patient was
still able to walk about one mile without problems however
in the last month he has started to notice increasing fatigue DISEASE
and dyspnea DISEASE on exertion. Three weeks ago he began coughing
with fevers DISEASE up to 101 and mild chills DISEASE intermittently. In the
last two weeks he has also noted increased sneezing and
severe non productive cough DISEASE . Two days ago he developed
[**2158-1-26**] constant stabbing chest pain DISEASE under the left breast
pleuritic in nature worse with cough DISEASE and unresponsive to
Nitroglycerin. It was also worse with walking. His episodes
of pain DISEASE occur approximately one hour at a time and he does
experience shortness of breath DISEASE but no nausea vomiting DISEASE
diaphoresis DISEASE or radiation. The patient denies headaches DISEASE neck
stiffness sore throat abdominal pain myalgias arthralgias DISEASE
and dysuria DISEASE . He has never been intubated. He does not have
a history of pneumonia DISEASE . In the Emergency Room he was
tachypneic into the 30's initially satting 77%. He was then
placed on a partial non rebreather mask at 15 liters and was
noted to sat in the low 90's. He was given 40 mg of IV Lasix
and diuresed about 150 cc of urine. Chest x-ray obtained in
the AW showed mild failure DISEASE and a retrocardiac opacity DISEASE . He
received 325 mg of Aspirin. Blood cultures times two were
obtained and he was given one dose of Levofloxacin. His
initial ABG was as follows: 7.49/32/38.

PHYSICAL EXAMINATION: On admission vital signs temperature
103.0 (rectal) pulse 109 blood pressure 98/44 respiratory
rate 26 O2 saturation 96% on 15 liters partial non
rebreather mask. General alert and oriented times three
pleasant in mild respiratory distress DISEASE with face mask on but
talking in full sentences. HEENT: Pupils were equal round
and reactive to light extraocular movements DISEASE intact
oropharynx was dry DISEASE . There is fullness of the neck DISEASE but no
lymphadenopathy DISEASE . Heart normal S1 and normal S2 no S3 no
murmurs or rubs. PMI non displaced. Lungs bronchial breath
sounds bibasilarly left greater than right. No rales.
Abdominal obese soft nontender non distended normoactive
bowel sounds no CVA tenderness DISEASE . Extremities 1Admission Date: [**2127-7-21**] Discharge Date: [**2127-7-30**]


Service: MED

Allergies DISEASE :
Bactrim / Amiodarone / Quinine / Codeine / Zithromax

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Abdominal Discomfort

Major Surgical or Invasive Procedure:
ERCP x 2
Endotracheal Intubation

History of Present Illness:
The patient is an 85 year old woman with PMH of ESRD DISEASE on HD HTN DISEASE
and DM who presented to the [**Hospital1 18**] ED on [**7-21**] with complaint DISEASE of
nausea vomiting abdominal pain DISEASE and diarrhea DISEASE x 3 days. The
patient also reported recent fever DISEASE and chills DISEASE . In the ED
patient had a low grade temperature of 100.5 degrees. Her
abdomen was slightly distended with no rigidity DISEASE or rebound.
Admission laboratory data were notable for WBC 6.2 elevated
transaminases and INR 3.7. Right upper quadrant ultrasound
disclosed a 5 mm gallstone DISEASE in the neck of the gallbladder.
There was also a 5mm gallstone in the common bile duct without
ductal dilatation. The patient was evaluated by surgery for her
choledocholithiasis DISEASE . The patient was also seen by the ERCP
fellow. The patient was not acutely ill last night so she was
admitted to the Medicine team with plan for ERCP today. She was
kept NPO and was administered IVF overnight.
This morning she was administered 4 U FFP to reverse her INR.
After receiving 2 U FFP she became hypoxic with O2 sats
dropping to the 70s. She was placed on 100% NRB DISEASE with
improvement in her O2 sats to the 90s. Prior to dialysis she
was given 100 mg IV Lasix with urine output (non measured). At
1:50 PM she was transferred to the Hemodialysis Unit for
initiation of hemodialysis. Approximately 1 L was removed yet
the patient remained in respiratory distress DISEASE with O2 sats in
the low 90s on NRB DISEASE . At 2:30 PM a respiratory code was called
since patient's O2 sats dropped to 70s on the NRB. The patient
was emergently intubated. ABG prior to intubation was
7.21/55/55. EKG disclosed new ST segment depressions in the
inferior and lateral leads. Following intubation the patient's
SBP dropped to 80s. She was administered approximately 500 cc
NS bolus and required Dopamine transiently. The patient was
transferred to the MICU for further management.


Past Medical History:
1. End stage renal disease DISEASE on hemodialysis via RIJ tunnelled
portacath. h/o failed left arm fistula DISEASE .

2. History of crescente glomerulonephritis DISEASE by renal biopsy
likely related to underlying vasculitis DISEASE .

3. Vasculitis DISEASE ANCA positive treated with chronic steroids.
Currently on steroid taper.

4. Chronic obstructive pulmonary disease DISEASE .

5. Steroid induced diabetes mellitus DISEASE .

6. Chronic anemia DISEASE related to end stage renal disease DISEASE .

7. History of hemorrhoids.

8. Atrial fibrillation DISEASE status post transesophageal
echocardiography and cardioversion currently on Atenolol and
Coumadin with an ejection fraction of over 55 percent on
echocardiogram in [**2126-3-2**].

9. Gastroesophageal reflux disease DISEASE with a normal EGD [**2126-6-2**].

10. Hypothyroidism DISEASE .

11. Hypertension DISEASE .


Social History:
Prior tobacco history over twenty years ago. She denies any
alcohol use. She
lives with her daughter [**Name (NI) **] [**Name (NI) 46**] who is her health
care proxy. The patient is full code. Primary care physician is
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**].

Family History:
Non-contributory

Physical Exam:
General: Elderly female lying in bed ETT in place.
VS: T: 100.7 BP: 104/48 initially 68/34 at 4 PM HR: 128
Resp: AC 550x14/100%/5 O2sat: 95%
HEENT: Sclerae DISEASE anicteric. PERRL. MMM. OP clear.
Neck: Obese. Supple. Difficult to assess JVP.
CVS: RRR. S1 S2. No m/r/g.
Lungs: Crackles in bases bilaterally.
Abd: Slightly distended. Admission Date: [**2149-9-2**] Discharge Date:

Date of Birth: [**2081-3-23**] Sex: M

Service:

CHIEF COMPLAINT: Shortness of breath cough DISEASE increased
dyspnea DISEASE on exertion.

HISTORY OF PRESENT ILLNESS: This is a 68 year old male with
a history of congestive heart failure DISEASE and an ejection
fraction of 30 to 40% status post three vessel coronary
artery bypass graft likely chronic obstructive pulmonary
disease and a [**2149-5-25**] admission for pansensitive
Streptococcus pneumococcal pneumonia DISEASE who presented yesterday
with shortness of breath DISEASE for two days a cough DISEASE productive of
white sputum chills DISEASE and increased dyspnea DISEASE on exertion. The
patient was in his usual state of health able to walk Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**]

Date of Birth: [**2141-12-5**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
catatonia DISEASE


Major Surgical or Invasive Procedure:
none


History of Present Illness:
51M w/ hx of depression DISEASE remote suicide DISEASE attempts and OCD DISEASE
presented to ED on [**1-8**] with c/o being nonconversant. He was
being weaned off abilify over the past 3 weeks due to
Admission Date: [**2133-9-3**] Discharge Date: [**2133-9-13**]


Service: MEDICINE

Allergies DISEASE :
Codeine / Penicillins

Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Left arm pain DISEASE

Major Surgical or Invasive Procedure:
Bone biopsy--left humerus

History of Present Illness:
82M with h/o prostate CA who p/w increasing pain DISEASE of left arm.
Sveral months PTA pt hit his arm. He went to local ER and was
told he had a mild fracture DISEASE treated with sling and pain DISEASE
control. however the pain DISEASE worsened over the last few months.
Pt came in to [**Hospital1 18**] for further evaluation. In [**Name (NI) **] pt noted to
have displaced left humerus fracture DISEASE likely pathologic. ROS of
notable for increased LE edema DISEASE .

Past Medical History:
Prostate CA s/p resection unknown status
CAD s/p CABG x 4 in [**2123**] with no further caths per family
Vfib arrest s/p ICD placement with 2 subsequent firings
CHF DISEASE unknown EF% followed by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 3236**] at [**Hospital1 3793**] Hospital (cards)
Afib DISEASE s/p pacemaker
hypercholesterolemia DISEASE
glaucoma DISEASE


Social History:
Lives at home with son and daughter heavily involved in care.
Tob: 1 ppd x many years quit 6y ago
Etoh: none
Illicits: none


Family History:
non contributory

Physical Exam:
TAdmission Date: [**2103-8-16**] Discharge Date: [**2103-8-19**]

Date of Birth: [**2070-11-24**] Sex: M

Service:

CHIEF COMPLAINT: Cough and shortness of breath DISEASE .

HISTORY OF PRESENT ILLNESS: This is a 32 year-old male with
a history of Down Syndrome autism DISEASE and [**2097**] pneumonia DISEASE
complicated with ARDS DISEASE who presents with one day of productive
cough DISEASE and low grade fever DISEASE as well as yellowish nasal
discharge for the past few days. The patient was prescribed
Doxycycline outpatient and took only two tablets before
refusing to take anymore. He then became short of breath.
The patient has had some fatigue DISEASE and anorexia DISEASE for the past
couple of days.

REVIEW OF SYSTEMS: No nausea vomiting abdominal pain DISEASE or
diarrhea DISEASE . The patient generally gets an infection DISEASE once every
two to three months especially infection DISEASE of the sinuses
which is treated with Amoxicillin. He is hospitalized back
in [**10-3**] to [**2098-11-4**] for similar symptoms which progressed
to ARDS DISEASE . At that time he was treated with Cefuroxime
Clindamycin and Erythromycin. He was intubated at that time
for 27 days. In the Emergency Room his saturation was low to
mid 90s on 80% on room air and 94 to 95% on a nonrebreather.

ALLERGIES: Haldol prolonged QT benzodiazepines and
narcotics positive to severe hypertension DISEASE .

MEDICATIONS AT HOME: None.

PAST MEDICAL HISTORY: Cataracts bilaterally status post
surgery. Downs and autism DISEASE with mental age level of 4 years
old recurrent sinusitis DISEASE . History of pneumonia DISEASE in [**2097**]
complicated by ARDS. [**2099**] tetanus DISEASE and pneumovax vaccination
with a negative PPD at that time.

SOCIAL HISTORY: He does not smoke or drink. He lives with
his parents.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION ON ADMISSION: Pulse 119. Blood
pressure 113/61. Respiratory rate 24. Temperature 103. 94%
on a nonrebreather. Generally this is an agitated male who
is breathing with much effort. HEENT pupils are equal
round and reactive to light and accommodation. Extraocular
movements intact. Mucous membranes are dry. Oropharynx is
difficult to examine. There is no sinus tenderness DISEASE . Neck is
supple. Chest there are rhonchi bilaterally. No wheezes or
crackles noted. There is some nasal flaring and use of
abdominal muscles to breath. Cardiovascular regular rate and
rhythm. Normal S1 and S2. No murmurs rubs or gallops.
Abdomen is soft obese which is nontender with decreased
bowel sounds. Extremities no clubbing cyanosis DISEASE or edema DISEASE .

LABORATORIES ON ADMISSION: White blood cell count 5.7 79.3%
neutrophils 10.6% lymphocytes 7.5% monocytes 0.6%
eosinophils and 2% basophils. Hemoglobin is 14.3 hematocrit
42.1 platelet 208 sodium 144 potassium 4.7 chloride 103
bicarb 31 BUN 17 creatinine 1.4 glucose 128 INR 1.3 PTT
28.8. Chest x-ray on [**8-15**] shows no signs of pneumonia DISEASE and
chest x-ray on [**8-16**] showed prominent pulmonary vasculature.
Blood cultures are pending. Arterial blood gas which is
polyvenous had a pH of 7.33 PCO2 60 PO2 48% and this is
done while on 85% on room air.

HOSPITAL COURSE: 1. Respiratory: The patient had hypoxia DISEASE
and probable hypercarbic respiratory failure DISEASE secondary to
tracheal bronchitis DISEASE and mucous plugging. The patient was
treated with antibiotics and given Albuterol Atrovent
nebulizer to improve the breathing. He was given a
nonrebreather but could not tolerate it. The patient was
switched over to 8 liters of oxygen on nasal cannula. The
patient then was able tolerate the nonrebreather for a couple
of hours before needing to switch over to a simple mask. The
patient began to have low oxygen saturations and required
intubation. However the patient's family decided to have
his code status switched from full code to DNR/DNI so the
patient was not intubated. The patient became progressively
more hypoxic until he expired. On the second day of
hospitalization the patient's respiratory distress was
further complicated with mucous plugging that caused right
upper lobe collapse.

2. Cardiovascular: The patient was tachycardic upon
admission secondary to dehydration DISEASE so he was given 125 cc an
hour of D5 half normal saline. His tachycardia DISEASE did resolve
transiently until he became quite anxious in the Intensive
Care Unit. He then became tachycardic secondary to anxiety DISEASE .

3. Renal: He had some prerenal azotemia DISEASE due to dehydration DISEASE
with a creatinine of 1.4. We did hydrate him with D5 half
normal saline.

4. Infectious disease: In regards to tracheal bronchitis DISEASE
he was given empiric treatment with Levaquin 500 mg
intravenous q.d. and Ceftriaxone 1 gram intravenous q.d.
However his right middle lobe opacity DISEASE did not improve. The
patient also had sinusitis DISEASE which was treated with the
antibiotics saline nasal spray and a 45 degree bed position.

On [**2103-8-19**] Mr. [**Known firstname **] [**Known lastname 3794**] expired at 9:05 a.m. due to
respiratory arrest DISEASE secondary to pneumonia DISEASE and lung collapse
that is secondary to mucous plugging.






[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 3795**]

Dictated By:[**Last Name (NamePattern1) 3796**]

MEDQUIST36

D: [**2103-8-21**] 16:57
T: [**2103-8-27**] 10:25
JOB#: [**Job Number 3797**]
Admission Date: [**2157-9-26**] Discharge Date: [**2157-10-3**]

Date of Birth: [**2092-5-20**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Thiopental Sodium

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**2157-9-26**] Coronary Artery Bypass Graft x 5 (LIMA to LAD SVG to
Diag SVG to OM1 to OM2 SVG to PDA)

History of Present Illness:
65 y/o male with PMH of CAD s/p MI in [**2147**] and [**2152**]. Recently
c/o DOE and underwent an ETT which showed a perfusion defect.
Underwent Cardiac cath which revealed severe three vessel
disease and referred for surgical intervention.

Past Medical History:
Myocardial Infarction DISEASE [**2147**]/[**2152**] Hypertension DISEASE
Hypercholesterolemia Diabetes Mellitus Obesity DISEASE h/o Bladder
cancer DISEASE

Social History:
Active smoker with approx. 1.5ppd x 40yrs. Denies ETOH use.

Family History:
Father with MI in 80's Brother with MI at 67.

Physical Exam:
VS: 58 14 160/90
Gen: WDWN male in NAD
Skin: w/d mult. nevi on torso
HEENT: NCAT EOMI PERRL OP benign with poor dentitian
Neck: Supple FROM -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft NT/ND DISEASE Admission Date: [**2196-4-27**] Discharge Date: [**2196-5-1**]

Date of Birth: [**2136-3-15**] Sex: F

Service: General Surgery

HISTORY OF PRESENT ILLNESS: This is a 60-year-old woman with
class III morbid obesity DISEASE with a body mass index of 66.9 who
has tried and failed numerous weight loss DISEASE programs. She
presents now to the Gastric [**Hospital 3798**] Clinic for the evaluation
of gastric restrictive surgery.

PAST MEDICAL HISTORY:
1. Obstructive sleep apnea DISEASE .
2. Hypertension.
3. Dyslipidemia.
4. Gastroesophageal reflux disease DISEASE .
5. Cholelithiasis.
6. Osteoarthritis.
7. Chronic low back pain.
8. Fibromyalgia.
9. Diverticulosis.
10. Hemorrhoids.
11. Recurrent panniculitis DISEASE .

PAST SURGICAL HISTORY: Past surgical history is significant
for exploratory laparotomy hysterectomy and bilateral
salpingo-oophorectomy in [**2183**] for benign disease. She is
status post supraclavicular node biopsy in [**2181**]. She is
status post paniculectomy in [**2189**] complicated by development
of a seroma DISEASE .

MEDICATIONS ON ADMISSION: Medications include Zestril
Cardizem hydrochlorothiazide potassium Zoloft Premarin
Celebrex albuterol inhaler multivitamin and aspirin.

ALLERGIES: No known drug allergies DISEASE .

HOSPITAL COURSE: The patient was admitted to the General
Surgery Service on [**4-27**] and underwent an uncomplicated
open gastric bypass surgery with open cholecystectomy.

The patient's postoperative course was notable for persistent
hypotension DISEASE with stout pressure in the 80s requiring fluid
boluses in order to maintain appropriate pressure and urine
output. An electrocardiogram was obtained and the was ruled
out for a myocardial infarction DISEASE .

She spent the following day in the Intensive Care Unit where
she was closely hemodynamically monitored. She subsequently
came out of the unit on postoperative day three and had a
relatively benign remainder of her hospital stay.

On postoperative day two she underwent a transesophageal
echocardiogram that demonstrated decreased left atrial
velocities but no other abnormalities.

She remained afebrile and on postoperative three was
restarted on her hydrochlorothiazide. Her intravenous fluids
were hep-locked DISEASE and her diet was advanced to a stage II.
Her patient-controlled analgesia was discontinued and she
was initiated on oral pain DISEASE medications which controlled her
pain DISEASE adequately.

By postoperative four the patient was tolerating a stage II
diet was passing gas and was advanced to a stage III diet.
Her Foley had been discontinued midnight the night before
and she was voiding without difficulty. Per the
recommendations of the Electrophysiology fellow the patient
was initiated on Coumadin for her new onset of atrial
fibrillation DISEASE .

DISCHARGE STATUS: The patient was subsequently discharged to
home.

CONDITION AT DISCHARGE: In stable condition.

DISCHARGE FOLLOWUP: Instructions to follow up with her
primary care physician to manage her outpatient Coumadin
dosing.

MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge included)
1. Coumadin 2.5 mg p.o. q.d.
2. Atenolol 25 mg p.o. q.d.
3. Zestril 20 mg p.o. b.i.d.
4. Premarin 0.625 mg p.o. q.d.
5. Celebrex.
6. Hydrochlorothiazide 25 mg p.o. q.d.
7. Potassium chloride 10 mEq p.o. q.d.
8. Procardia.
9. Roxicet elixir 5 cc to 10 cc p.o. q.4-6h. p.r.n. for
pain DISEASE .
10. Zantac elixir 150 mg p.o. q.d.
11. Multivitamin.
12. Vitamin B12.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**] M.D. [**MD Number(1) 3800**]

Dictated By:[**Last Name (NamePattern1) 3801**]

MEDQUIST36

D: [**2196-5-17**] 15:14
T: [**2196-5-18**] 08:42
JOB#: [**Job Number 3802**]
Admission Date: [**2113-5-10**] Discharge Date: [**2113-5-14**]

Date of Birth: [**2035-11-8**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: This is a 77 year old gentleman
with past medical history of asthma DISEASE recent Group A
Streptococcus non-necrotizing fasciitis DISEASE Dr. [**Last Name (STitle) **] for his
recent infection DISEASE the day of admission. At the appointment Dr.
[**Last Name (STitle) **] noted that the patient had a significant cardiac rub. A
chest x-ray was ordered which documented that there was
significant cardiomegaly DISEASE compared to his previous chest x-ray one
week prior to admission. Dr. [**Last Name (STitle) **] referred the patient to
the [**Hospital6 256**] Emergency Department for
echocardiogram to evaluate for a possible pericardial effusion DISEASE .
In the Emergency Department the patient was noted to have
significant accumulation of pericardial fluid and
physiological evidence of cardiac tamponade DISEASE . The patient was
admitted from the Emergency Department to the Cardiac
Intensive Care Unit for hemodynamic monitoring. The
cardiology fellow was consulted regarding the need for
pericardiocentesis DISEASE . Given the patient's blood pressure was
stable the decision was made to hold off on pericardiocentesis DISEASE
until the morning following admission so the patient could have
the full attention of all members of the Cardiac Catheterization
Laboratory.

PAST MEDICAL HISTORY:
1. Asthma.
2. Gout.
3. Gastroesophageal reflux disease.
4. Mild anemia DISEASE .

MEDICATIONS ON ADMISSION:
1. Amoxicillin 500 q. 8 hours.
2. Singulair.
3. Albuterol.
4. Salmeterol.
5. Fosamax 70 q. Tuesday.
6. Calcium with Vitamin D. 7. Fluticasone.

PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1 heart
rate 55 blood pressure 151/56 respiratory rate 22 oxygen
saturation 98% on room air. In general she was a
well-appearing elderly male in no apparent distress. Head
eyes ears nose and throat was anicteric. Facial muscles
were symmetric. Mucous membranes were moist.
Cardiovascular borderline tachycardia DISEASE notable soft
vocal-like DISEASE rub at the left lower sternal border. The patient
had a pulsus paradoxus at 22. Pulmonary the patient was
noted to have basilar crackles no wheezes or rhonchi DISEASE . The
abdomen with active bowel sounds soft DISEASE nontender. The
patient had mild mid epigastric tenderness DISEASE as well as right
upper quadrant tenderness. There was no apparent guarding
no rebound no evidence of acute abdomen. Extremities he
had mild 1Admission Date: [**2158-1-5**] Discharge Date: [**2158-1-9**]

Date of Birth: [**2105-1-12**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3814**]
Chief Complaint:
DKA/Uremia DISEASE

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
52 yo man with DM 1 and triopathy as well as PVD DISEASE and CRI
(followed by transplant) p/w 3 days of hyperglycemia DISEASE and N/V DISEASE of
coffee-ground emesis DISEASE this am. Patient denies infectious symptoms DISEASE
or cardiac symptoms DISEASE . Of note had a stress test 3 days ago read
as normal. EKG in ED with lateral ST depressions and Admission Date: [**2137-4-23**] Discharge Date: [**2137-4-29**]

Date of Birth: [**2090-12-9**] Sex: M

Service: CARDIOTHOR

CHIEF COMPLAINT: Aortic regurgitation.

HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male
with a history of coronary artery disease DISEASE status post stent
to left anterior descending. Subsequent to this procedure
patient developed aortic regurgitation DISEASE . He was evaluated by
Cardiology and he underwent a catheterization on [**2137-4-9**] which showed aortic regurgitation DISEASE 4Admission Date: [**2110-1-6**] Discharge Date: [**2110-1-10**]

Date of Birth: [**2046-5-20**] Sex: F

Service:

ADMISSION DIAGNOSES:
1. Rheumatic heart disease DISEASE .
2. Aortic and mitral valve disease DISEASE .

DISCHARGE DIAGNOSES:
1. Aortic valve stenosis DISEASE .
2. Mitral valve regurgitation DISEASE .
3. Status post aortic valve replacement with 21 mm
pericardial valve mitral valve repair with 28 mm [**Doctor Last Name 405**]
annuloplasty band.

HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
woman with a history of rheumatic heart disease DISEASE . She has
known aortic and mitral valve disease DISEASE . Her last
echocardiogram was done on [**2109-12-12**] which revealed an ejection
fraction of 60%. Moderately severe MR DISEASE [**First Name (Titles) 151**] [**Last Name (Titles) 3841**] enlarged
LA were demonstrated as well as moderate to severe aortic
stenosis with an estimated valve area of 0.9 cm squared.
There was also significant pulmonary hypertension DISEASE with PA
pressures estimated at 64 mmHg. Most recent ETT was negative
in [**2105**] and performed for brief complaints of chest
discomfort. Clinically patient reports that she is very
active. She walks several miles a day cross country skiis
and is able to cut and stack wood for her fireplace. Over
the past three weeks however she has noticed decrease in
activity tolerance along with chest pain DISEASE and mild shortness
of breath that occurs with vigorous exertion. She reports
that this discomfort can take up to several hours to resolve.
She has never taken nitroglycerin. She is now referred for
cardiac catheterization. Patient denies claudication
orthopnea edema DISEASE PND lightheadedness.

PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia.
Smoking history quit 20 years ago. Insulin dependent
diabetes mellitus DISEASE . Rheumatic heart disease DISEASE . Autoimmune iron
disease. Hypothyroidism. Osteoporosis. Bilateral carotid
bruit without significant carotid disease DISEASE . Breast cancer DISEASE
status post chemotherapy and surgery.

PAST SURGICAL HISTORY: Status post left mastectomy in [**2086**].
Cholecystectomy in [**2079**].

MEDICATIONS ON ADMISSION: Miacalcin nasal spray Levoxyl 200
mcg q.d. Lipitor 10 mg q.d. enalapril 5 mg q.d. Celebrex
200 mg b.i.d. Protonix 40 mg q.d. folate 1 mg q.d. NPH 15
units q.h.s. regular and Humalog insulin sliding scale.

PHYSICAL EXAMINATION: In general the patient was an elderly
woman who appeared younger than her stated age and was in no
acute distress. Vital signs were stable afebrile. Height
was 5'2Admission Date: [**2131-12-23**] Discharge Date: [**2131-12-29**]


Service: MEDICINE

Allergies DISEASE :
Bactrim / Amiodarone / Quinine / Codeine / Zithromax /
Lisinopril / Citalopram / Ciprofloxacin / Hydralazine

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
Intubation
PICC line placement
Hemodialysis
Transfusion of one unit packed red blood cells


History of Present Illness:
A [**Age over 90 **] year-old female with past medical history of chronic
obstructive pulmonary disease Wegener's granulomatosis DISEASE recent
admission [**Date range (1) 2374**] for acute on chronic renal failure DISEASE
with decision to initiate hemodialysis at that time and hospital
stay complicated by left lower lobe Moraxella pneumonia
presenting with altered mental status. Per her daughter the
patient was home this past week and accidentally took trazodone
50 mg two days prior to admission which had been discontinued
due to confusion DISEASE . Her confusion/visual hallucinations DISEASE improved
the day prior to admission. She complained of increased
productive cough DISEASE and oxygen requirement (previously intermittent
2L NC now continuous) over the past two days responding to an
increase in nebulizer treatments. The patient was noted to be
lethargic this afternoon responsive to sternal rub. When
aroused she was oriented x 3 and moving all extremities well
however. The patient was noted to be Admission Date: [**2191-4-8**] Discharge Date: [**2191-4-22**]


Service: MICU

HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
African-American male with a known history of prostate cancer carcinoid syndrome DISEASE and interstitial lung disease DISEASE
secondary to asbestos exposure with an admitted in [**2190-2-21**] for pneumonia DISEASE .

At baseline the patient has shortness of breath and dyspnea DISEASE
on exertion. Two days prior to admission the patient
believes that he acquired a cold because he subsequently
developed a cough DISEASE that was nonproductive. The patient had
mild wheezing DISEASE and a temperature as high as 100.1 degrees one
day prior to admission. The patient's shortness of breath
increased with exertion and when lying flat. The patient
stated that walking him Admission Date: [**2100-8-8**] Discharge Date: [**2100-8-12**]

Date of Birth: [**2015-2-6**] Sex: M

Service: [**Year (4 digits) 662**]

Allergies DISEASE :
Procainamide

Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
Altered mental status hypotension DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
85 yo M w/ PMH of bladder ca CAD HTN DISEASE who is transferred from
OSH for concern for urosepsis DISEASE . Pt presented to OSH day prior to
admission here with shaking chills DISEASE and altered mental status. Pt
reports he has had urinary incontinece over the past few days
which is abnormal for him denies any dysuria DISEASE . He reports
awaking in the middle of the night with shaking chills DISEASE and does
not recall what else happed but that his girlfriend must have
taken him to the [**Name (NI) **]. ON arrival to the OSH he was febrile DISEASE to
103.3 and given 1 dose of tylenol. UA at the OSH was positive
for UTI DISEASE . His BP dropped to 86/46 and he was given 3-4L of fluids
with improvement in BP to 101/48. They did a head CT for
concern of his altered mental status in the setting of
anticoagulation which was per report negative. He was
transferred here for further care given that this is where he
has all of his providers.

On arrival to the [**Hospital1 18**] ED he was febrile DISEASE at 102.5 rectally and
was given 650mg of tylenol. He was initially hemodyanmially
stable however his BP did drop down transiently into the 70s
and he was given 2L bolus of fluid with good response in his BP
and was stable in the 110s prior to transfer to the floor.
Repeat blood and urine cultures were performed and he was
admitted for possible urosepsis DISEASE .

On arrival to the MICU the patient is sleepy and complains of
some chronic left sided pain DISEASE . He denies any recent suprapubic
pain nausea vomiting flank pain DISEASE . He has not had a UTI DISEASE since
[**2091**] and he denies any hematuria DISEASE or changes in his urine color.


10 point ros is negative except per above


Past Medical History:
-Recurrent bladder tumors- followed by Dr. [**Last Name (STitle) 3854**] recent urine
cytology from cystoscopy on [**3-/2100**] showed clusters of highly
atypical urothelial cellssuspicious for urothelial carcinoma DISEASE .
-history of prostatitis DISEASE dx at [**Hospital1 2025**]
-ATRIAL FIBRILLATION - amiodarone /warfarin
-CARPAL TUNNEL SYNDROME
-CHOLELITHIASIS
-CORONARY ARTERY DISEASE
CABG in [**2070**]: SVG to LAD SVG to OM SVG to PDA cath in
[**2086**] severe native disease occluded SVG to RCA and OM patent
SVG to LAD redo CABG
-HYPERTENSION
-INGUINAL HERNIA
-RENAL INSUFFICIENCY

Social History:
Social History: lives alone in an apartment and has a service
that he pays for were people can come help him if needed. Has a
son and is in a long term relationship. 40pack year former
smoker quit years ago. Denies alcohol. Sings in acapella at
[**Hospital **] rehab




Family History:
Noncontributory

Physical Exam:
Admission Physical Exam:
Vitals: 97.8 115/64 52 100% 2L
General: Alert oriented no acute distress sleepy in bed
HEENT: Sclera anicteric MMM oropharynx clear EOMI PERRL
Neck: supple JVP not elevated no LAD
CV: Bradycardic diastolic murmur at the LUSB not radiating
Lungs: Clear to auscultation bilaterally no wheezes rales DISEASE
rhonchi
Abdomen: Protuberant soft non-tender non-distended bowel DISEASE
sounds present no organomegaly DISEASE no rebound or guarding
GU: yellow urine in foley
Ext: Warm well perfused 2Admission Date: [**2132-12-3**] Discharge Date: [**2132-10-1**]

Date of Birth: [**2098-11-23**] Sex: M

Service:

HOSPITAL COURSE: The patient is a 34 year old male status
post motor vehicle accident on [**2132-7-9**] status post
talectomy on the right foot and bilateral ....... here for a
right tibiocalcaneal fusion and a right iliac bone graft and
internal hardware placement.

The patient tolerated the procedure well. On postoperative
day number one he had a maximum temperature of 101.5 that
spontaneously defervesced. He was maintained on intravenous
antibiotics throughout the course of his stay. His incision
was clean dry and intact.

The patient was seen by physical therapy and after plain
films were reviewed it was deemed appropriate to allow the
patient to have weightbearing as tolerated on the left lower
extremity with a walker boot in place and nonweightbearing on
the right ankle. He was discharged to rehabilitation on an
AFO boot and is to follow up with Dr. [**Last Name (STitle) 284**] in two
weeks. Dr. ...... will be following him as an outpatient
regarding his sciatic nerve issues.






Dictated By:[**Name8 (MD) 4385**]
MEDQUIST36

D: [**2132-12-5**] 14:52
T: [**2132-12-5**] 15:17
JOB#: [**Job Number 4386**]
Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-16**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Promethazine/Codeine

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain DISEASE and syncope DISEASE

Major Surgical or Invasive Procedure:
s/p AVR(19mm Mosaic porcine valve)/Aortic endarterctomy [**2-3**]
s/p pacer placement [**2-10**]


History of Present Illness:
This 84WF presented to [**Hospital1 18**] [**Location (un) 620**] [**2150-1-19**] with CP and was in
AF. She was treated with Lopressor and Dilt and became
asystolic DISEASE . She was resuscitated and transferred to [**Hospital1 18**]. She
was found to have aortic stenosis DISEASE and is now admitted for AVR.

Past Medical History:
Aortic stenosis DISEASE
recent Afib DISEASE
HTN DISEASE
Pseudogout of R knee
Hypothyroidism DISEASE
GERD EGD [**2144**]
Breast Cancer DISEASE [**2102**] s/p left mastectomy
s/p Hysterectomy
Osteoporosis DISEASE on Evista
Aortic Stenosis
DJD DISEASE Hand
Iron Deficiency Anemia DISEASE [**2146**]
Left Shoulder Impingement Syndrome
Spinal Stenosis DISEASE : MRI [**10-26**] showed severe stenosis of spinal canal and recesses at L4-L5 DISEASE
Osteoarthritis DISEASE : Right lower extremity pain DISEASE and lower back pain
Paronychia
Actinic keratosis DISEASE on R face

Social History:
Social history is significant for the absence of current tobacco
use. She previously smoked 1 ppd but quit 40 years ago. There
is no history of alcohol abuse DISEASE . She lives at home with a
boarder.


Family History:
There is no family history of premature coronary artery disease DISEASE
or sudden death.

Physical Exam:
Elderly WF in NAD
AVSS
HEENT: NC/AT oropharynx benign
Neck: supple FROM no lymphadenopathy DISEASE or thyromegaly carotids
2Admission Date: [**2165-10-10**] Discharge Date: [**2165-10-16**]

Date of Birth: [**2107-12-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Iodine

Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Hyperkalemia DISEASE

Major Surgical or Invasive Procedure:
Paracentesis

History of Present Illness:
57 year old male with history of EtOH and HCV cirrhosis DISEASE
(genotype 1 treatment-naive) complicated by ascites DISEASE hepatic
encephalopathy DISEASE with most recent EGD in [**2163**] showing no varices
as well as seizure disorder polysubstance abuse DISEASE on methadone
with recent admission for hepatic encephalopathy DISEASE now referred
from his PCP's office for hyperkalemia DISEASE and acute renal failure DISEASE .
He admits that he is often noncompliant with her medications
and is almost completely reliant on his sister [**Name (NI) **] to
administer them (he can't even say which meds he's on).

His last admission ([**9-13**] - [**2165-9-19**]) was notable for
hyponatremia hyperkalemia DISEASE acute kidney injury DISEASE and
encephalopathy DISEASE . He underwent large volume paracentesis (4.7L)
from which the peritoneal fluid grew GPCs and he was treated
with vancomycin for 48 hours until cultures returned showing one
bottle growing peptostreptococcus (believed to be a
contaminant). Antibiotics were discontinued at that time and he
had no further signs of infection DISEASE for the remainder of his
hospital stay. His acute kidney injury was thought to be related
to hypovolemia DISEASE from overdiuresis improved with IV albumin. His
hyperkalemia DISEASE was treated with kayexylate and the hyponatremia DISEASE
improved with fluid restriction (132 on discharge). His hepatic
encephalopathy DISEASE resolved with lactlose. He was given
ciprofloxacin 250mg daily for SBP prohpylaxis (given low
peritoneal fluid protein) and spironolactone was decreased from
200 to 100mg Admission Date: [**2111-11-9**] Discharge Date:


Service: Medical-[**Hospital1 **]

ADMITTING DIAGNOSIS: Pneumonia DISEASE .

DISCHARGE DIAGNOSIS: MSSA line infection DISEASE .

CHIEF COMPLAINT: Right upper quadrant pain DISEASE .

HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 4410**] is an 82-year-old
male with history of end stage renal disease DISEASE on hemodialysis
atrial fibrillation peptic ulcer disease hypertension SVT DISEASE
and triple A who presented with right upper quadrant pain
right flank pain nausea retching DISEASE and decreased appetite.
Three days prior to admission after his routine dialysis he
noted some shakes and later that day he noted some right
upper quadrant pain that was intermittent. Associated
symptoms included right flank pain nausea retching and
decreased appetite with poor oral intake. The pain DISEASE was not
associated with eating or position. He describes no previous
episodes that were similar to this. At his scheduled
dialysis on the day of admission the dialysis center was
unable to access his catheter. Of note on [**2111-6-29**] he was
admitted to [**Hospital1 2025**] for line sepsis DISEASE with MSSA and treated with
Vanc and Gent and then switched to Nafcillin for 6 weeks
despite a TEE that was negative for vegetation DISEASE .

REVIEW OF SYSTEMS: Negative for headache DISEASE visual changes
chest pain shortness of breath PND orthopnea diarrhea DISEASE
change in color of stool rashes DISEASE or skin changes. He does
complain of chronic constipation DISEASE and longstanding decreased
sensation in his lower extremities.

PAST MEDICAL HISTORY: Hypertension BPH end stage renal
disease on hemodialysis SVT DISEASE CVA PVD DISEASE with severe
claudication in left leg status post left transmetatarsal
amputation gastritis DISEASE and esophagitis atrial fibrillation DISEASE
triple A 4.3 cm in 12/98 4.6 cm in 3/00 right inguinal
hernia GI bleed DISEASE [**2111-6-5**] while hospitalized at [**Hospital1 2025**] for line
sepsis DISEASE .

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS: Amiodarone 200 mg q day Nephrocaps one mg q
day Phos-Lo 667 mg three tablets tid TUMS 500 mg three
tabs tid Percocet 2 tabs q h.s.

FAMILY HISTORY: Mother renal failure DISEASE . No diabetes DISEASE
hypertension DISEASE coronary artery disease DISEASE or cancer DISEASE .

SOCIAL HISTORY: Positive for tobacco two packs per day for
65 years occasional alcohol no drugs. He is a retired iron
worker. He has three children and lives alone.

PHYSICAL EXAMINATION: On admission temperature 99.0 pulse
76 respirations 18 blood pressure 116/70 88% on room air
to 93% on two liters. General lying in bed in no apparent
distress. HEENT: Pupils equal round and reactive to light
extraocular movements DISEASE intact. Oropharynx clear. Moist mucus
membranes. CV quiet heart sounds DISEASE regular rate and rhythm
no murmurs. Pulmonary clear to auscultation bilaterally.
Abdomen soft non distended mild right upper quadrant
tenderness DISEASE to deep palpation no rubs or gallops normoactive
bowel sounds. Back no CVA tenderness DISEASE . Extremities no
edema DISEASE nontender left transmetatarsal amputation unable to
palpate DP pulses bilaterally but feet were warm. Neuro
alert and oriented times three cranial nerves II DISEASE through XII
grossly intact.

LABORATORY DATA: White count 13.2 83 polys no bands 10
lymphs 6 monos hematocrit 41.5 platelet count 182000 PT
13.4 INR 1.3 PTT 30.2 sodium 141 potassium 5.2 chloride
94 CO2 27 BUN 69 creatinine 10.5 glucose 87 blood
cultures were sent. Chest x-ray showed cardiomegaly DISEASE and
small bilateral pleural effusions DISEASE septal line consistent
with mild interstitial edema DISEASE . Cannot rule out left lower
lobe pneumonia. CT triple A measures 4.8 cm maximum
unchanged from [**3-/2110**] no appendicitis DISEASE or diverticulitis DISEASE small
right pleural effusion bibasilar consolidation gallstones DISEASE
right inguinal hernia without obstruction DISEASE or strangulation DISEASE .

HOSPITAL COURSE: While in the Emergency Room the patient's
symptoms greatly improved. He was tolerating po in the
Emergency Room. He had eaten a hamburger and has very little
pain DISEASE . The patient was admitted for further evaluation of
this right upper quadrant pain DISEASE . Blood culture quickly grew
out gram positive cocci which later were found to be MSSA.
The patient was started on Vanc 1 gm IV q day. On hospital
day #2 the patient began to complain of dyspnea DISEASE and pleuritic DISEASE
chest pain DISEASE . He desatted to 87% on three liters which came
out to 90% on 100% non rebreather face mask. His temperature
was 101.7. ABG showed PO2 of 72 PCO2 41 PH 7.9. The EKG
showed atrial fibrillation DISEASE . He was given 2 mg of Morphine
for the pain DISEASE and they attempted to wean the patient off the
non rebreather. However he became hypotensive DISEASE with blood
pressure 80's/50's pulse 100-140. He began to become
somnolent and did not respond to a 250 cc IV fluid bolus and
was transferred to the MICU. While in the ICU the antibiotic
coverage was broadened to include Ceftriaxone and Flagyl.
The patient's pressures were supported with Neo and the
catheter was changed to a right groin Quinton catheter. The
patient was stabilized and transferred back to the floor on
hospital day #4. On hospital day #5 a TTE was performed that
showed a mildly dilated left atrium and a small mass or
artifact seen on the aortic valve in the LV outflow tract.
At this point the patient had grown out 6 bottles of
Oxacillin sensitive staff. The patient's antibiotic coverage
was now changed to Oxacillin and Gentamycin. The goal was
Oxacillin for six weeks and Gentamycin for two weeks.
Throughout the stay the patient received hemodialysis three
times a week without complications. On hospital day #8 a
repeat chest x-ray was done that showed an increase in the
pleural effusion DISEASE on the right with an appearance of
loculation. After prolonged discussions with the patient
the patient declined to have the effusion tapped. The
patient continued to have difficulty with access throughout
his stay and MR venogram was performed and the venogram
showed complete SVC occlusion DISEASE above the azygous right
brachiocephalic right subclavian and right IJ occlusion and
partial clot in the left brachiocephalic. At this time it
was felt that it was unlikely to be able to get a PICC line
in the patient. So after discussion with ID DISEASE antibiotic
coverage was now going to be changed to Oxacillin while an
inpatient and Vancomycin dosed at hemodialysis as an
outpatient again for total treatment of 6 weeks. On
hospital day #10 the patient developed diarrhea DISEASE the diarrhea DISEASE
was non bloody had no abdominal pain DISEASE it was sent for C.
diff and as of hospital day 12 one sample had come back
negative. On hospital day #9 also the right groin Quinton
was removed without complication and on hospital day 11 a
tunneled groin cath was placed by IR. This tunneled groin
cath was to be used for hemodialysis only. Discussions with
transplant surgery were begun and the plan is for an AV
fistula DISEASE after completion of the antibiotics. Discussions
were also begun as to option for central access besides groin
line. On hospital day #11 it was felt that the patient was
appropriate for acute rehab. He was seen by case management
and referrals were placed. The total antibiotic therapy was
started on [**11-12**] and the end date is [**12-23**]. He will receive
Oxacillin while an inpatient which will be changed to
Vancomycin dosed at hemodialysis as an outpatient.




[**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 910**]

Dictated By:[**Last Name (NamePattern1) 4411**]

MEDQUIST36

D: [**2111-11-20**] 09:17
T: [**2111-11-20**] 09:16
JOB#: [**Job Number 4412**]
Admission Date: [**2112-5-23**] Discharge Date: [**2112-5-27**]


Service: ACOVE

HISTORY OF PRESENT ILLNESS: This is an 83 year old male
with multiple medical problems including end-stage renal
disease on hemodialysis who had initially presented on [**5-23**]
at Hemodialysis with decreased p.o. intake and one week of
cough DISEASE productive of clear sputum. In Hemodialysis the
patient was also noted to be rigoring at which time blood
cultures were drawn and the patient was subsequently sent
home. At home the patient experienced generalized weakness DISEASE
and so presented to the Emergency Department.

In the Emergency Department initial vital signs were a
temperature of 103.0 F.Admission Date: [**2113-4-18**] Discharge Date: [**2113-5-2**]


Service: MEDICAL/VASCULAR

CHIEF COMPLAINT: Left foot cellulitis DISEASE .

HISTORY OF PRESENT ILLNESS: This is an 83 year-old male with
extensive past medical history sent from dialysis for
evaluation and treatment who has been unable to walk or the
past eight months. He de orthopnea DISEASE paroxysmal nocturnal
dyspnea fevers DISEASE or chills nausea or vomiting DISEASE .

PAST MEDICAL HISTORY: End stage renal disease DISEASE on
hemodialysis hypertension DISEASE MSSA sepsis DISEASE treated chronic
atrial fibrillation DISEASE history of peptic ulcer disease DISEASE history
of abdominal aortic aneurysm DISEASE history of benign prostatic
hypertrophy DISEASE history of cerebrovascular accident DISEASE history of
peripheral vascular disease DISEASE history of gastrointestinal
bleed history of prostate carcinoma DISEASE . Left lower lobe
pneumonia DISEASE in [**2112-5-4**]. History of gastritis DISEASE and
esophagitis DISEASE . History of right inguinal hernia DISEASE without
repair.

PAST SURGICAL HISTORY: Hemorrhoidectomy remote amputation
of right first toe remote left TMA DISEASE in [**2110-5-5**].

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS ON ADMISSION:
1. Levofloxacin 250 mg po q 48 hours.
2. Flagyl 500 t.i.d.
3. Colace.
4. Senna tabs.
5. Protonix.
6. Zolpidem 5 mg q.d.
7. Sevelamer 800 mg t.i.d.
8. Nephrocaps one q.d.
9. Amiodarone 200 mg po q.d.
10. Coumadin 1 mg q.d.

ADMISSION LABORATORIES: CBC with a white blood cell count of
6.9 poly 72 lymphocytes 18 hematocrit 33 platelets 255
BUN 9 creatinine 3.4 K 3.5. Echocardiogram done in
[**Month (only) 956**] showed normal ejection fraction with mitral regurgitation DISEASE and aortic regurgitation DISEASE noted.

The patient was begun on Vanco Levo and Flagyl antibiotics.
Coumadin was continued. Protonix was continued and vascular
was consulted regarding management. Vascular examination
showed a pleasant male in no acute distress. HEENT
examination was unremarkable. carotids were without bruits DISEASE .
Heart was a regular rate and rhythm. The lungs were
diminished at the right base and abdominal examination had a
palpable aortic aneurysm DISEASE . The foot examination showed a left
foot cold with ischemic appearing black ulceration on the
left medial heel and ankle with no erythema DISEASE fluctuance or
drainage. The pulse examination showed palpable femorals on
the right dopplerable on the left. Popliteal was
dopplerable on the right absent on the left. The dorsalis
pedis pulses were absent bilaterally. The patient PT was
dopplerable on the right and absent on the left. The foot
x-ray showed no evidence of osteomyelitis DISEASE . Arteriogram on
[**2113-3-30**] showed a abdominal aortic aneurysm DISEASE with a left common
iliac aneurysm DISEASE with plaque DISEASE . The distal superficial femoral
artery popliteal and BK [**Doctor Last Name **] diseased the single vessel run
off via the peroneal was reconstituted to the dorsalis pedis
pulse. There was no posterior tibial pulse.

Recommendations were to hold his Coumadin normalize his INR
begin heparinization for goal PTT between 40 and 60 obtain
MRI/MRA of the left leg and the aorta to evaluate the aorta
and in flow disease consider cardiac workup with
echocardiogram and PMIBI continue antibiotics broad
spectrum follow culture results and tailor as necessary.
Multipodus splint to the right foot to prevent heel
ulcerations. Echocardiogram was obtained which demonstrated
symmetric left ventricular hypertrophy DISEASE . This was a
suboptimal technical quality study so focal wall motion
could not be excluded. The overall ventricular function EF
was greater then 55%. There was a mild aortic stenosis DISEASE and
mitral leaflets appeared thickened but they were unable to
adequately assess the mitral regurgitation DISEASE . There was mild
pulmonary hypertension DISEASE . Compared to previous study on
[**2113-1-18**] there is probably a similar aortic gradient that is
slightly higher. The patient underwent a PMIBI. There were
no anginal DISEASE or ischemic changes but the patient did have
premature ventricular contractions DISEASE and premature atrial
contractions. His nuclear portion showed an abnormal study
with severe fixed defect involving the basilar portion of the
inferior wall. The ejection fraction was calculated at 54%
and on visual inspection it is in the range of 65 to 70.

Medical attending evaluated the patient and a moderate
cardiac risk for surgery. The patient had a CTA of the
abdomen and pelvis to determine abdominal aortic aneurysm DISEASE .
Findings demonstrated intrarenal abdominal aortic aneurysm DISEASE of
4.9 by 5.2 cm. There is an aneurysm DISEASE of the right proximal
common iliac artery which measures 4.1 by 2.9 cm. There is
an aneurysm DISEASE of the left common iliac which measures 1.7 by
2.5 cm. There is an aneurysm DISEASE in the proximal right internal
iliac artery which measures 1.4 to 2.0. There is dense
vascular calcification DISEASE and multiple venous collaterals seen
along the anterior subcutaneous tissues of the abdomen with
collateral flow to the right common femoral vein. There is
moderate stenosis of the right external iliac artery. The
celiac superior mesenteric arteries DISEASE are patent. There is
dense calcification DISEASE involving the ostium of the left renal
artery and dense calcifications DISEASE at the origin of the right
renal artery. There are extensive venous intercostal
collaterals along the anterior abdominal wall. These
findings are consistent with severe vena cava occlusion DISEASE . The
right inguinal hernia DISEASE contains small bowel DISEASE . There is no
evidence of obstruction DISEASE . Incidentally there was gallstones DISEASE
in the gallbladder. Bilateral adrenal enlargement DISEASE may
represent adrenal hyperplasia DISEASE . Diverticulosis without
evidence of diverticulitis DISEASE . The patient underwent an
abdominal aortic angio with left leg run off. There showed
significant infrarenal aortic atherosclerotic DISEASE changes with
aneurysmal DISEASE dilatation extending to the common iliac. There
is diffuse atherosclerotic ulcerative plaque DISEASE of the bilateral
external and internal iliac arteries. There is severe
disease of the left superficial femoral artery which
occluded at the adductor canal. The left PFA is occluded and
above and below knee popliteal arteries are occluded. There
is reconstruction of a diffusely diseased attenuated
peroneal which reconstitutes the dorsalis pedis.

After careful review of the arteriogram and CTA a long
discussion with the patient's daughter and the patient was
determined being as a high risk and his comorbidities and
recommendations were a left below the knee amputation. The
patient consented to that and underwent on [**2113-4-27**] a left
below the knee amputation. He tolerated the procedure well
and he was transferred to the PAC in stable condition. He
remained hemodynamically stable. He was transferred to the
VICU for continued monitoring and care. Initial dressing was
removed on postoperative day number two. The wound was
clean dry DISEASE and intact. The skin edges were intact with no
ecchymosis DISEASE and no drainage. Physical therapy and
occupational therapy began to work with the patient. renal
continued to follow the patient for hemodialysis needs.
Percocet caused the patient to be confused so he was started
on Tylenol #3. Renal recommended that the patient only
receive narcotics a single dose q 24 hours supplement the
patient's break through pain DISEASE with extra strength Tylenol
tablets two q 4 to 6 hours prn for pain DISEASE . The remaining
hospitalization was unremarkable. The patient was discharged
to rehab.

DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg po q.d.
2. Nephrocaps one q.d.
3. Sevelamer 800 mg t.i.d.
4. Protonix 40 mg po q.d.
5. Acetaminophen 325 to 650 mg po q 4 to 6 hours prn for
pain DISEASE .
6. Colace 100 mg b.i.d.
7. Senna tablets one b.i.d.
8. Metoprolol 25 mg b.i.d. hold for systolic blood pressure
less then 100 heart rate less then 60.
9. Albuterol Ipratropium multi dose inhaler one to two puffs
q 6 hours.
10. Coumadin 1 mg q.h.s.

DISCHARGE DIAGNOSES:
1. Severe peripheral vascular disease DISEASE with left leg ischemia DISEASE
status post below the knee amputation.
2. End stage renal disease DISEASE on hemodialysis.
3. PMIBI with fixed inferior basilar wall defect DISEASE ejection
fraction greater then 55%.






[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 4417**]

Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36

D: [**2113-5-1**] 10:13
T: [**2113-5-1**] 10:23
JOB#: [**Job Number 4418**]
Admission Date: [**2113-5-2**] Discharge Date: [**2113-5-5**]


Service: MEDICINE

HISTORY OF PRESENT ILLNESS: This is an 84-year-old man with
multiple medical problems including end-stage renal disease DISEASE
on hemodialysis previous hypertension atrial fibrillation DISEASE
peptic ulcer disease DISEASE recently status post left below the
knee amputation from [**4-27**] and discharged from [**Hospital1 **] on [**5-1**] and was transferred to rehab.

He returned to us on [**5-1**] because of increased shortness of breath DISEASE and hypoxia DISEASE and was slightly obtunded. The patient
had dialysis on [**5-1**] and he was initially sating 96% on 2
liters. In the Emergency Department he was given a dose of
ceftriaxone and Levaquin for a pneumonia DISEASE and left pleural
effusion that was drained 800 cc of fluid.
Postthoracentesis his saturations went up to 96-97%. He did
have a small pneumothorax DISEASE as a complication of this
procedure. However then his oxygen saturations fluctuated
in the low 90s. His blood pressure transiently dropped to
systolic blood pressure 75 which responded to fluid boluses.

In the Emergency Department it was discussed with Renal
there was no need to dialyze at that time. He was evaluated
by Surgery for his left below the knee amputation which
appeared to be healing well as per Surgery.

PAST MEDICAL HISTORY:
1. End-stage renal disease DISEASE on hemodialysis Tuesdays
Thursdays Saturdays.
2. Hypertension DISEASE .
3. Atrial fibrillation DISEASE .
4. Peptic ulcer disease DISEASE .
5. Abdominal aortic aneurysm DISEASE which is 4.3 cm in [**2108**].
6. Benign prostatic hypertrophy DISEASE with prostate cancer DISEASE .
7. Cerebrovascular accident DISEASE .
8. Peripheral vascular disease DISEASE .
9. Left below the knee amputation.
10. History of MSSA line sepsis DISEASE .
11. Gastritis DISEASE .
12. Esophagitis DISEASE .
13. Right inguinal hernia.
14. Gastrointestinal bleed DISEASE in [**2111-6-5**].
15. Chronic lower back pain.
16. Previous admissions for persistent left lower lobe
retrocardiac pneumonia DISEASE . CT scan in the past had shown a
mass. The patient on a previous admission had refused
bronchoscopy therefore the question of whether this
postobstructive pneumonia DISEASE was never worked up.

MEDICATIONS ON ADMISSION:
1. Amiodarone 200 mg q day.
2. Nephrocaps one cap q day.
3. Renagel of 800 mg tid.
4. Protonix 40 mg q day.
5. Colace 100 mg [**Hospital1 **].
6. Coumadin 1 mg q day.
7. Lopressor 25 mg [**Hospital1 **].
8. Senna.

SOCIAL HISTORY: He is a two pack per day smoker for 65
years occasional alcohol use. He is a retired iron worker
and lives alone.

EXAMINATION ON ADMISSION: His temperature was 99.2 blood
pressure 102/45 heart rate 83 respiratory rate 18 and
sating at 91% on 4 liters. In general he was awake. His
HEENT: Pupils are equal and reactive but were about 1 mm
bilaterally. Extraocular movements DISEASE are intact. Dry mucous
membranes. Chest: He had decreased breath sounds on the
left with coarse breath sounds DISEASE on the right. Cardiac:
Regular rate and rhythm with a systolic murmur distant DISEASE
heart sounds. Abdomen: Positive bowel sounds. Soft
nontender nondistended. Extremities: Left below the knee
amputation tender stump bandage right leg showed no edema DISEASE
with poor toenail care. Neurologic: Mental status: He was
awake and talks. Alert to person and [**Hospital1 **]
and was speaking nonsense at times.

LABORATORIES ON ADMISSION: Sodium of 140 potassium 5.9
chloride 104 bicarb 21 BUN 38 creatinine 6.5 glucose 72
nonhemolyzed specimen. His white count was 9.4 hematocrit
of 33.5 platelets of 200 83% neutrophils 13% lymphocytes.
His INR was 1.5 with a PT of 14.8 and a PTT of 24.6. CK of
4006 CK MB of 17 MBI was 0.4 and troponin of 1. His
pleural fluid showed protein 2.3 glucose 92 LDH 84 albumin
of 1.3. His blood cultures were drawn.

Electrocardiogram showed a junctional rhythm with
questionable ST depressions DISEASE in V3 through V6 but appears
older consistent with electrocardiogram on [**2113-4-19**]. Regular
rate at 86 with some low voltages.

Chest x-ray showed progression of a left pleural effusion DISEASE
with partial layering and the right pleural effusion DISEASE appeared
to be stable.

The patient was initially admitted to the MICU from [**5-1**] to
[**5-3**].

1. Pulmonary: The patient presented with shortness of breath DISEASE
and hypoxia DISEASE . Chest x-ray showed a large left pleural
effusion which was much increased from his previous chest
x-ray. His left effusion was tapped in the Emergency Room.
His sats have been maintaining in the low 90s on a
nonrebreather given that the probability of a pneumonia DISEASE and
intermittent hypertension DISEASE . Blood cultures were sent. This
was thought to be sepsis DISEASE from a pneumonia DISEASE . He was started on
ceftriaxone and Levaquin.

His antibiotics were then changed to ceftazidime and was
continued on Vancomycin since he had previously been on this
for colonization DISEASE by MRSA in his toes. Eventually his sputum
cultures did grow out Staph coag positive species and his
ceftazidime was then switched over to levofloxacin and Flagyl
po on [**2113-5-4**].

The possibility of pulmonary embolus DISEASE was considered given his
hypotension DISEASE his acute respiratory decompensation DISEASE and
increased left pleural effusion DISEASE however the patient has
since refused CTA. Patient's saturations over the course of
the hospitalization has remained approximately 94-95% on the
Medical floor when he was transferred on [**2113-5-4**].

2. Cardiovascular: The patient has a history of atrial
fibrillation hypertension DISEASE and abdominal aortic aneurysm DISEASE .
Given his new hypotension DISEASE his blood pressure medications
were held (his beta blocker was held). He was continued on
amiodarone and was kept in regular rhythm. His
anticoagulation he had been subtherapeutic as per records on
his last admission and had not been anticoagulated. He was
refusing Heparin drip as well because he was refusing blood
draws and understood the risks and benefits of not being on
Heparin and was restarted on Coumadin in hospital.

His blood pressure has remained in the 85-100 range
tolerating ................ greater than 55.

His last issue was his elevated CK MB and troponin. His
elevated CK was thought to be secondary to his below the knee
amputation since his MB index was low thought to be secondary
to his renal failure DISEASE . His enzymes were cycled and remained
stable. His CK continued to fall.

3. Renal: Patient with end-stage renal disease DISEASE on
hemodialysis. He continued on hemodialysis on Tuesdays
Thursdays and Saturdays. He had some degree of
rhabdomyolysis DISEASE and the Renal team did not feel that there
was any urgent need for dialysis initially. He was continued
on Nephrocaps and Renagel.

4. GI: Given his history of peptic ulcer disease DISEASE and
gastrointestinal bleed DISEASE he was given Protonix. His
hematocrit had remained stable throughout hospitalization
and his vascular surgery had been following him for his left
below the knee amputation. He is stable from that standpoint
and has been having dressing changes as needed. He has a
multipodas boot on the right foot that should be continued
given his tenderness DISEASE on the right heel.

His code status was changed in the hospital from full code
from DNR/DNI. The patient has been refusing blood draws and
understands the risks of refusing both the CTA of the chest
and refusing blood draws.

DISCHARGE DIAGNOSES:
1. Left lower lobe pneumonia DISEASE .
2. Left pleural effusion DISEASE status post thoracentesis with small
pneumothorax DISEASE .
3. Hypotension DISEASE .
4. Sepsis DISEASE .
5. Paroxysmal atrial fibrillation DISEASE .
6. End-stage renal disease DISEASE .

MEDICATIONS AT DISCHARGE:
1. Amiodarone 200 mg po q day.
2. Aspirin 325 mg po q day.
3. Combivent 1-2 puffs q6h.
4. Renagel 800 mg po tid.
5. Nephrocaps one cap po q day.
6. Vancomycin dosed when Vancomycin level is less than 15 at
hemodialysis.
7. Levofloxacin 250 mg po q48h starting on [**2115-5-7**].
8. Flagyl 500 mg po tid to stop on [**5-14**].
9. Coumadin 1 mg po q hs to be titrated for a goal of [**2-6**]
INR.
10. Protonix 40 mg po q day.
11. Senna one tablet po bid prn.
12. Colace 100 mg po bid.
13. Folic acid 1 mg po q day.

TREATMENTS: He is to continue on hemodialysis on Tuesdays
Thursdays Saturdays and to be monitored for his INR on
Coumadin. He is to have dressing changes to the left below
the knee amputation and to keep the left leg straight. He
is to followup with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
and he should also have multipodas boot to the right foot
while in bed sheepskin and Physical Therapy for his left
below the knee amputation. He is to be discharged to
[**Hospital3 4419**].



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**] M.D. [**MD Number(1) 1212**]

Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36

D: [**2113-5-5**] 08:31
T: [**2113-5-5**] 08:35
JOB#: [**Job Number 4420**]
Admission Date: [**2113-11-29**] Discharge Date: [**2113-12-2**]

Date of Birth: [**2058-2-22**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4421**]
Chief Complaint:
Nausea DISEASE and Vomiting DISEASE .

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
55 year-old female with recently diagnosed stage IIIA fallopian
tube adenocarcinoma DISEASE who presented to oncology clinic complaining
of ongoing nausea vomiting DISEASE and weakness DISEASE . She received her
first cycle of chemotherapy consisting of intravenous Taxol and
carboplatin on [**2113-11-1**] and last week received her second cycle
consisting of intravenous Taxol and intraperitoneal cisplatin
followed by aggressive antiemetics with dolasetron Emend and
compazine. Ever since her recent chemotherapy she has had some
abdominal pain nausea vomiting DISEASE and was feeling tired. She
has not been able to keep any food down but has been tying to
drink Boost and Ensure as tolerated. She has not had any
diarrhea DISEASE . She describes also intermittent fevers/chills at
home without any headache DISEASE change in vision chest pain DISEASE SOB
excessive thirst or urination DISEASE or change in her bowel habits.
In oncology clinic she was found to be dehydrated with a serum
sodium in the 108 range and potassium in the low 2 range and is
admitted for further management.
.
In the ED she was afebrile with normal vital signs and a
normal mental status exam (per her husband). She was given IV
normal saline potassium replacement and was admitted to the
[**Hospital Unit Name 153**] for further management. The patient's sodium improved with
normal saline. The etiology of her hyponatremia DISEASE and hypokalemia DISEASE
was unclear but was possibly secondary to SIADH exacerbated by
dehydration DISEASE and electrolyte loss ( vomiting DISEASE ) or secondary to a
component of Fanconi's syndrome DISEASE . Hypertonic saline and
democycline were not necessary. The patient's cortisol
stimulation test and TSH were within normal limits. Celexa was
discontinued due to its association with SIADH. The patient's
IVF were discontinued at noon the day of transfer to the OMED
floor with sodium improving to 128 and normalization of her
potassium.

Past Medical History:
1. Stage IIIA grade III left-sided fallopian tube cancer DISEASE status
post total abdominal hysterectomy bilateral
salpingo-oophorectomy left pelvic lymph node dissection DISEASE
peritoneal washings and omental biopsy on [**2113-10-10**].
2. Hypertension DISEASE
3. Major Depression DISEASE
4. History of gastrointestinal bleed DISEASE

Social History:
She lives in [**Doctor Last Name 792**]with husband and two of her three
sons. [**Name (NI) **] husband is a cardiologist. She denies tobacco or
EtOH use.


Family History:
NC

Physical Exam:
VITAL SIGNS: 98 85 160/100 20 98% RA DISEASE
GENERAL: Pale female with alopecia DISEASE tired-appearing in NAD
HEENT: MM dry DISEASE with cracked red lips anicteric no sinus tenderness DISEASE
NECK: Supple no LAD JVP flat
HEART: RRR with a flow murmur no S3 or S4
CHEST: Clear to ausculatation and percussion bilaterally
ABDOMEN: Soft obese NT ND palpable IP port in LUQ without
erythema DISEASE
EXTREMITIES: No c/c/e pale nail beds normal cap refill
NEUROLOGIC: AAO x 3 appropriate CN intact strength 5/5 in
bilateral upper and lower extremities. No sensory defect. Did
not assess gait
SKIN: Flushed erythematous apearance of neck
MUSCULOSKELETAL: No joint effusions noted

Pertinent Results:
[**2113-11-29**] 12:30PM SODIUM-108* POTASSIUM-2.0* CHLORIDE-65*
[**2113-11-29**] 03:15PM GLUCOSE-175* UREA N-22* CREAT-1.0 SODIUM-109*
POTASSIUM-2.8* CHLORIDE-66* TOTAL CO2-29 ANION GAP-17
[**2113-11-29**] 03:25PM GLUCOSE-171* LACTATE-3.2* KAdmission Date: [**2189-12-1**] Discharge Date: [**2189-12-11**]

Date of Birth: [**2123-2-13**] Sex: M

Service: VSU


CHIEF COMPLAINT: Chronic right ankle infection DISEASE with unstable
joint.

HISTORY OF PRESENT ILLNESS: This is a 66-year-old male with
a nonhealing right malleolar wound and fracture DISEASE for the last
2 years who underwent a right ankle traction and open
reduction internal fixation. The patient has had multiple
admissions for wound infections DISEASE and multiple IV antibiotic
courses. Most recent admission was [**2189-9-28**] for a
wound infection DISEASE . The patient recently complained of a
temperature elevation on [**2189-11-30**] and now is to be
admitted to Dr.[**Name DISEASE (NI) 1392**] service for continued IV
antibiotics. The patient initially was discharged on
daptomycin and followed by VNA.

PAST MEDICAL HISTORY: Type 2 diabetes DISEASE with triopathy DISEASE
endstage renal disease DISEASE secondary to diabetes DISEASE status post
cadaver transplant in [**2182**] history of coronary artery
disease status post CABG in [**2178**] history of peripheral
vascular disease DISEASE right ankle fracture DISEASE in [**2188-6-6**] with an
open reduction internal fixation status post hardware
removal chronic osteomyelitis DISEASE .

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS: Percocet dicloxacillin 100 mg twice a day
gabapentin 1600 mg twice a day Lasix 20 mg twice a day
Sensipar 30 mg daily metoprolol 25 mg daily ranitidine 150
mg daily. There are two other medications that the patient is
on of which the handwriting is not decipherable at this
time.

SOCIAL HISTORY: The patient is a nonsmoker is married and
lives with his spouse.

PHYSICAL EXAMINATION: Vital signs 94.6 94 18 blood
pressure 144/88 oxygen saturation 93% in room air. Blood
sugar fingerstick was 291 on admission. General appearance:
Alert cooperative white male in no acute distress. HEENT
exam: Mild right eye ptosis DISEASE . Neck is supple without
lymphadenopathy DISEASE or carotid bruits DISEASE . Lungs are clear to
auscultation bilaterally. Chest is with a well healed median
sternotomy incision. Heart is a regular rate and rhythm with
a systolic ejection murmur II/VI nonradiating DISEASE . Abdomen is
soft nontender obese. Extremities: Right malleolus with
punctate lesion with draining and surrounding erythema DISEASE . Pulse
exam shows palpable radial pulses femoral pulses
bilaterally. The right DP and PT are dopplerable signals. The
left DP and PT are dopplerable signs. Neurological exam is
nonfocal.

HOSPITAL COURSE: The patient was admitted to the vascular
service. His dicloxacillin was continued. Vancomycin and
Flagyl were instituted. He was continued on his preadmission
medications. He was seen by Dr. [**Last Name (STitle) 1391**] and advisement was
made for him to undergo a below the knee amputation. The
patient accepted the recommendation. Transplant nephrology
was consulted to follow the patient during his
hospitalization. [**Last Name (un) **] was consulted for hyperglycemic
management. Daily SK5 levels were obtained. He required
minimal adjustment in his immunosuppression. He continued on
his Lantus with a Humalog sliding scale with improvement in
his glycemic control. On [**2189-12-3**] he underwent a
right BKA without incident. He was transferred to the PACU in
stable condition. At the end of his surgical procedure
intraoperatively the patient became hypotensive DISEASE with
systolic blood pressure in the 60s and he was given Neo 200
mcg x2 and epinephrine 5 mg x2. The patient went into a
monomorphic VT 4 minutes at a rate of 130. He was given
lidocaine 100 mg IV bolus and amiodarone 125 mg over 15
minutes. The patient converted to sinus rhythm. An
intraoperative TEE showed severe biventricular failure DISEASE .
Dopamine was started at 5 mcg/kg/minute. Blood pressure
improved. He was transferred to the PACU and then to the ICU
for continued care. Serial enzymes were obtained. Repeat echo
was obtained on the 28th which demonstrated left ventricular
wall thickness and cavity dimensions were obtained by 2-D
images. He has severely depressed left ventricular ejection DISEASE
fraction. He had multiple regional wall motion abnormalities DISEASE .
His aortic valve was moderately thickened leaflets. There
were no masses or vegetations DISEASE on the aortic valve. No aortic
insufficiency DISEASE . The mitral valve tricuspid valve DISEASE were normal
with trivial MR [**First Name (Titles) **] [**Last Name (Titles) **]. The pulmonic valve and artery were
unremarkable. The pericardium showed no pleural effusion DISEASE .
Aortic valve area was calculated at 1.3 cm squared normal is
3 cm squared. Gradient peak was 32 mm. There was no
intracardiac thrombus DISEASE noted on the primary or the secondary
echo. The ejection fraction was calculated at 30% to 40%. IV
heparin was begun to maintain a goal PTT between 40 and 60.
The patient's Dobutamine was weaned with hopes to extubate.
Pulse exam remained unchanged. The right amputation site was
clean dry dressing. He remained on bedrest in the SICU.
Cardiac enzymes: Base was 20 peaked at 96 for the CK. CK MBs
were not obtained. His troponins were 0.01 and 0.03. The
patient's Swan was converted to a CVL on [**2189-12-4**].
The patient continued on heparin was extubated and
transferred to the VICU for continued monitoring and care on
[**2189-12-5**]. Cardiology was requested to see the
patient on [**2189-12-6**] who felt the patient was
hemodynamically stable and his atrial fibrillation DISEASE was rate
controlled. We should continue the heparin while his INR is
less than 2 and his goal INR should be [**1-9**] and recommend
metoprolol tartrate twice a day versus single dosing. They
recommended aspirin 81 mg and simvastatin 20 mg daily.
Hyperglycemia DISEASE control remained relatively good. He did not
require adjustment in his Lantus. His premeal coverage was
adjusted. Vancomycin ciprofloxacin and Flagyl were
discontinued on [**2189-12-7**]. The patient remained
afebrile. Foley was discontinued. Peripheral line was placed
and the central line was discontinued. The patient had been
advanced to a regular diet and ambulation to chair was begun.
On [**2189-12-8**] postoperative day 5 the patient
continues on IV heparin/Coumadinization conversion. Serial
coags were monitored. Physical therapy will see the patient
and make recommendations regarding disposition planning
being a new amputation if he will go to rehabilitation. Will
talk to infectious disease DISEASE Dr. [**Last Name (STitle) 2379**] regarding discontinue
the doxycycline. The remaining hospital course the patient
will be discharged when medically stable and bed available at
rehabilitation. At the time of discharge discharge
medication instructions will be dictated.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**] [**MD Number(1) 2381**]

Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2189-12-8**] 11:23:20
T: [**2189-12-8**] 14:38:59
Job#: [**Job Number 2383**]
Admission Date: [**2178-11-12**] Discharge Date: [**2178-12-3**]

Date of Birth: [**2112-4-25**] Sex: F

Service: MEDICINE

HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
female who was initially admitted on [**2178-11-12**]
complaining of increased weakness DISEASE and groin pain DISEASE since nine
days prior to admission when she had a fall. Since the fall
the patient had been basically confined to her bedroom did
not drink or eat and lived on some water coffee cigarettes
and occasional beer. According to her family the patient
had been not very mobile for some time prior to admission
mostly because of severe exertional dyspnea DISEASE . However
despite her dyspnea DISEASE she continued to smoke two packs of
cigarettes per day.

On admission the patient denied any fevers chills nausea DISEASE
vomiting dizziness DISEASE chest pain DISEASE .

PAST MEDICAL HISTORY: Significant for chronic obstructive
pulmonary disease DISEASE hypertension DISEASE history of vitamin B12
deficiency.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS ON ADMISSION: Tiazac 240 per day Premarin
0.625 mg per day Provera 2.5 mg per day clonazepam 1 mg
three times a day Atrovent two puffs four times a day
albuterol four puffs four times a day Ventolin as needed.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Lives alone lifelong smoker at least two
packs per day. Drinks ethanol on a regular basis.

PHYSICAL EXAMINATION: On admission vital signs 97.7 blood
pressure 90/60 heart rate 101 respiratory rate 29 oxygen
saturation 90% on 2 liters. In general she was alert and
oriented x 3 very cachectic DISEASE in no apparent distress. Her
pupils were equal reactive responsive to light and
accommodation extraocular muscles were intact oropharynx
was clear. The skin was without rashes. The neck showed no
jugular venous distention DISEASE no bruits DISEASE . The lungs showed
decreased air movement and were wheezy DISEASE . Heart regular rate
and rhythm plus murmur. The abdomen was soft nontender
with normal active bowel sounds DISEASE . Extremities were clear no
clubbing cyanosis DISEASE or edema DISEASE good pulses distally.
Neurological examination was nonfocal.

LABORATORY DATA: On admission significant for a white
blood cell count of 23.7 hematocrit 43.5 platelets 651.
Liver function tests were normal. Chemistries were normal.
Creatinine 0.5. Chest x-ray showed a right upper lobe
infiltrate. Hip films were suspicious for a left femoral
neck fracture DISEASE . Electrocardiogram showed sinus tachycardia DISEASE .

HOSPITAL COURSE: This is a 66-year-old female with severe
chronic obstructive pulmonary disease hypertension DISEASE who
presented with right upper lobe pneumonia DISEASE and a possible left
hip fracture DISEASE and generalized weakness. She is a long-time
smoker and has also had ethanol abuse on a regular basis.

She was given intravenous fluids antibiotics levofloxacin
intravenously nebulizer therapy inhalers and oxygen. She
was put on ethanol and nicotine withdrawal precautions given
deep venous thrombosis DISEASE prophylaxis and was seen by
Orthopaedic Surgery consult. Orthopaedic service decided to
treat her left hip fracture DISEASE nonoperatively because it was
stable and impacted in an acceptable but not ideal position.
Pinning the hip in that position would have been technically
difficult and has drawbacks and because of her severe
chronic obstructive pulmonary disease DISEASE and pneumonia DISEASE it was
decided to avoid surgery. She was discontinued from her
Premarin because this increases the risk of deep venous
thrombosis DISEASE . She would need to walk with a walker for four to
six more weeks for which she would need a rehabilitation
hospital or home care with services.

On [**11-15**] the patient was found to have oxygen saturations as
low as 53%. She was placed on 100% non-rebreather which
improved her saturations to 100%. The patient was noted to
have a weak cough DISEASE . Oral/nasal suctioning was started and
the patient was breathing better. Changed to 4 liters of
nasal cannula oxygen saturating 95%. However she continued
to be more somnolent and difficult to arouse. An arterial
blood gas showed a pH of 7.3 PCO2 89 PO2 200 on 100%
non-rebreather. Chest x-ray showed worsening right upper
lobe pneumonia DISEASE .

The patient was transferred to the Medical Intensive Care
Unit for further airway management. She did not tolerate
BiPAP secondary to depressed DISEASE mental status and secretions
and therefore was intubated for pulmonary toilet and more
adequate respiration to protect mental status.

Later that day after a lengthy discussion with the son
[**Name (NI) 1704**] and daughter [**Name (NI) **] it was learned that the patient
had been completely noncompliant with medical care prior to
admission. Her oldest daughter [**Name (NI) **] is her health care
proxy but feels that [**Name (NI) 1704**] should be making the medical
decision as Mrs. [**Known lastname 4427**] lives with him and is close to him.
Mrs. [**Known lastname 4427**] had previously expressed to her primary care
physician that she wanted to have all medical interventions
but no be on a breathing machine for a prolonged period of
time. Given her acute decompensation DISEASE and pneumonia DISEASE there
was reversible component to her situation however it was
explained to them the severity of the underlying lung disease DISEASE
and the chance of prolonged intubation. [**Doctor First Name **] expressed that
her mother has been severely depressed DISEASE for the past 15 years
since her husband and two children died and has been
committing slow suicide by abusing her body with tobacco
ethanol and caffeine. She has refused interventional therapy
or medication. It was decided at that point that she would
be made Do Not Resuscitate but would continue on the
ventilator.

The patient continued to be treated with Levaquin and Flagyl
for possible aspiration pneumonia DISEASE and was continued on the
respirator but had a difficult time being weaned from the
ventilator. Chest x-ray showed emphysematous blebs in her
left lower lobe and continuing right pleural effusion DISEASE that
layered.

By [**11-19**] her pressure support on the ventilator was
decreased to 10 although she failed a spontaneous breathing
trial. Pleural effusion DISEASE was stable acid fast bacilli
negative x 3. She was evaluated by Nutrition and started on
tube feeds Impact with fiber at 40 cc/hour.

On [**11-20**] she had to be placed back on pressure support of 12
and 5 because of failure DISEASE to tolerate the lower pressures.
Plans were made on that day for percutaneous tracheostomy if
she continued to fail her wean. She was treated for eight
out of 21 days with levofloxacin and eight of 14 days with
Flagyl.

She continued to demonstrate difficulties in weaning from the
ventilator. Atrovent was added on [**11-22**] and she was
continued on her antibiotics.

On [**11-21**] it was discussed with the family and it was decided
that it would be attempted to avoid tracheostomy and attempt
ventilatory wean because the wishes of the patient and the
family were to not have long-term intubation on a
tracheostomy and that she would not want to be reintubated.
However a short trial of pressure support [**3-28**] with increased
respiration decreased tidal volume subsequent arterial
blood gas of 7.31/84/54 and the patient had to be put back
on pressure support of 15 with 5 of PEEP. She spiked to 101
and was cultured grew 4Admission Date: [**2180-5-24**] Discharge Date: [**2180-6-2**]

Date of Birth: [**2112-4-25**] Sex: F

Service: FENARD INTENSIVE CARE UNIT

CHIEF COMPLAINT: Hypoxia.

HISTORY OF PRESENT ILLNESS: This is a 68-year-old woman with
a history of chronic obstructive pulmonary disease DISEASE history
of right upper lobe pneumonia DISEASE status post prolonged
intubation with trache and PEG placements from [**2177-11-24**] to [**2178-12-25**] full exercise tolerance at
baseline chronic productive cough DISEASE with thick-clear sputum
but otherwise not on home O2 or po prednisone who has been
in her usual state of health until about a week prior to
admission when she started to experience increased fatigue DISEASE
and shortness of breath and productive cough DISEASE . But otherwise
no fevers chills DISEASE no overt upper respiratory infection DISEASE
urinary tract infection DISEASE or abdominal symptoms.

Two days prior to admission her family noticed a dramatic
worsening of shortness of breath DISEASE and increased sputum
production but otherwise no change in the color or blood in
the sputum. She also had significant worsening of appetite for two days. She fell at home the day prior to admission
due to extreme weakness. She was on the floor for about 15
minutes but no loss of consciousness DISEASE . She was brought into
the Emergency Room by her family.

Her head CT scan was negative for hemorrhage DISEASE . Her shortness DISEASE
of breath was much better with nebulizers and IV steroids.
However the next day while she was still in the Emergency
Room she was noticed to have increased lethargy DISEASE and was
electively intubated for an arterial blood gas of pH 7.24
pCO2 84 and pO2 of 73. She became significantly hypotensive DISEASE
after intubation and required 10 liter normal saline
resuscitation. She was started on Neo-Synephrine for blood
pressure support. She was given a dose of levofloxacin and
Vancomycin for empiric coverage of possible sepsis DISEASE . Her
chest x-ray and chest CT scan in the Emergency Department
suggested right upper lobe pneumonia DISEASE or other processes.

PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease DISEASE .
2. Severe emphysema DISEASE and bronchitis DISEASE . Pulmonary function tests
in [**2178-6-24**] showed a FVC of 1.85 liters FEV1 0.73
liters and a FEV1/FVC ratio 39%.
3. Hypertension DISEASE .
4. Vitamin B12 deficiency.
5. Alcohol and benzodiazepine dependency.
6. History of tuberculosis DISEASE exposure versus infection DISEASE .
7. Osteoporosis DISEASE .
8. Status post right upper lobe pneumonia DISEASE in [**2178-10-24**]
to [**2178-12-25**] with prolonged intubation with trache and
PEG placement.

ALLERGIES:
1. Bactrim with nausea DISEASE .
2. Orajel with benzocaine with dermatitis DISEASE .

MEDICATIONS ON ADMISSION:
1. Combivent two puffs [**Hospital1 **].
2. Serevent two puffs [**Hospital1 **].
3. Vitamin B12 250 mcg po q day.
4. Flovent two puffs [**Hospital1 **].
5. Klonopin 1 mg po bid.
6. Atrovent.
7. Remeron 30 mg q hs.
8. Diltiazem 120 mg po bid.
9. Multivitamins one tablet po q day.
10. Stool softeners.
11. Oxycodone 5 mg prn for pain DISEASE .

SOCIAL HISTORY: Two packs per day until last year after the
pneumonia DISEASE . Still smokes now and then. Regular alcohol use.
Lives with her son and grandson.

EXAM ON ADMISSION: Temperature 97.0 heart rate 74 blood
pressure 85/35 respiratory rate 16 O2 saturation 100% on
FIO2 100% with vent setting of tidal volume 350 rate of 16
PEEP of 5 FIO2 1.0. General: She is intubated but easily
arousable thin chronically sick appearing but otherwise in
no acute distress. Head and neck examination is anicteric.
Oropharynx is clear. Cardiovascular: Regular rate and
rhythm. Lungs: Equal breath sounds bilaterally
significantly prolonged expiratory phases. Abdomen is soft
normal bowel sounds. Extremities no edema DISEASE . Neurologic:
Moves all extremities. Lines with Foley and ET tube.

LABORATORIES UPON ADMISSION: Arterial blood gas 7.24 84 73
preintubation. After intubation 7.07 25 459.

Complete blood count: White count of 34.3 hematocrit of
43.5 platelets 474. PT of 16.0 PTT 53.4 INR of 1.7.
Sodium 135 potassium 4.6 chloride 96 bicarb 31 BUN 9
creatinine 0.5 glucose of 133. Urinalysis is negative.

Chest x-ray showed increased capacity and pleural thickening
at the right upper lobe concerning for infection DISEASE TB versus
aspergillosis DISEASE versus actinomycosis DISEASE versus mucomycosis and
also need to rule out neoplasts.

Chest CT scan: Diffuse emphysematous changes with bullae DISEASE
right apical thick walled cavity suggesting semi-invasive
aspergillus DISEASE versus TB versus actinomycosis DISEASE versus
mucomycosis versus neoplasts multilobular pneumonia DISEASE versus
aspiration multiple liver lesions.

Head CT scan: No evidence of intracranial hemorrhage DISEASE .

Sputum Gram stain showed [**11-25**]Admission Date: [**2110-8-26**] Discharge Date: [**2110-8-30**]

Date of Birth: [**2053-7-14**] Sex: F

Service: VASCULAR

HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
female with multiple medical problems who presented with
gangrene DISEASE of the right lower extremity required admission for
pain DISEASE control intravenous antibiotics and ultimately for
right below the knee amputation.

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post coronary artery
bypass graft complicated by sternal wound infection DISEASE .
2. History of Methicillin resistant Staphylococcus aureus
bacteremia DISEASE in [**2109-8-3**].
3. Diet controlled diabetes mellitus DISEASE .
4. Hypertension.
5. Hypercholesterolemia.
6. Significant tobacco use.
7. History of wound abscess in the right lower extremity
which grew out Methicillin resistant Staphylococcus aureus.
8. Status post AV fistula DISEASE in [**2105**].
9. Status post coronary artery bypass graft times three that
was complicated by the sternal wound infection DISEASE [**8-3**] by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].
10. Status post right femoral to below knee popliteal bypass
with PTFE done in [**3-4**] followed by a right first toe
amputation completed in [**3-4**].
11. History of cesarean section.
12. Questionable history of Penicillin allergy but she does
state otherwise that she has no known drug allergies.

MEDICATIONS ON ADMISSION:
1. Nephrocaps one tablet p.o. once daily.
2. Norvasc 5 mg twice a day.
3. Gabapentin 300 mg q Monday Wednesday and Friday after
hemodialysis.
4. Tramadol 50 mg p.o. twice a day p.r.n.
5. Trazodone 100 mg q.h.s.
6. Medroxyprogesterone 2.5 mg once daily.
7. Albuterol MDI.
8. Pantoprazole 40 mg p.o. once daily.
9. Calcitriol 0.25 mcg once daily.
10. Aspirin 81 mg p.o. once daily.
11. Epogen 20000 units q Monday Wednesday and Friday with
hemodialysis as well as using MSIR 50 mg q12hours.

The patient was admitted with increasing right lower
extremity pain DISEASE and low grade temperature. Her admission
white count was noted to be 10.4 with a left shift
hematocrit 40.0 with a platelet count of 244000.
Prothrombin time was 13.7 and INR was 1.3 with a partial
thromboplastin time of 28.0. She was on dialysis with a
blood urea nitrogen and creatinine of 74 and 6.9
respectively. She had an admission potassium of 7.6 which
was repeated in the Emergency Department and shown to be 8.0.
Hyperkalemia DISEASE was emergently treated with calcium chloride
bicarbonate dextrose insulin Lasix as she does make some
urine as well as emergent hemodialysis and Kayexalate.

Upon the day of admission she went to dialysis and received
her hemodialysis. Her potassium postdialysis was 4.1. She
was otherwise feeling OK except complaining of persistent
right lower extremity pain DISEASE .

PHYSICAL EXAMINATION: Her admission examination was notable
for a temperature of 100.1 pulse 90 blood pressure 158/60
respiratory rate 18 oxygen saturation 94% in room air. She
was a cachectic DISEASE female who appeared older than her stated
age. The pupils are equal round and reactive to light and
accommodation. Extraocular movements DISEASE are intact. The sclera
were anicteric. She had no jugular venous distention DISEASE and no
carotid bruit. The heart was regular with no gallop. The
lungs were clear but decreased throughout. The abdomen was
soft nontender scaphoid no hepatosplenomegaly DISEASE no
pulsatile masses and no bruit. She had palpable femoral
pulses bilaterally. Popliteal pulses were not palpable.
Distal pulses in the right lower extremity were absent. She
had some dry DISEASE and wet gangrene DISEASE involving the right forefoot
with a failed right first toe amputation site that clearly
had some purulent exudate.

She was admitted for intravenous antibiotics and started on
Vancomycin Levofloxacin and Flagyl for her hemodialysis.
Over the next couple days she was resuscitated adequately
and ultimately on [**2110-8-26**] she went to the operating room
and received a right below the knee amputation.
Postoperatively she did well. She was ruled out by enzymes
and kept on telemetry times 24 hours and was uneventful. Her
postoperative white blood cell count was 9.6 and hematocrit
was 41.8. Platelet count was 157000. Blood urea nitrogen
and creatinine were 58 and 6.3 with a potassium of 5.3. Her
phosphate was noted to be elevated at 11.8. Therefore in
hospital medications she had her Calcitriol stopped and she
was started on Amphojel and PhosLo. The Amphojel was
continued for a total of three days of therapy starting on
[**2110-8-28**] and to end on [**2110-8-31**]. Over the next couple days
her pain DISEASE was appropriately controlled with Dilaudid PCA
although the patient demanded that the Dilaudid DISEASE did not work
for her. Therefore she was requesting Morphine. This was
given concomitantly and resulted in some mental status
changes and confusion DISEASE which quickly resolved upon removal of
her narcotic. She had a foot culture from [**2110-8-25**] that
grew out Methicillin resistant Staphylococcus aureus. Blood
cultures from [**2110-8-24**] were negative. By postoperative day
number four she continued on triple antibiotics. Her
temperature maximum was 100.1 but a current of 97.4 pulse
82 blood pressure 130/70 respiratory rate 18 96% oxygen
saturation in room air. Her fingerstick was mildly elevated
but she was noncompliant and was not taking a diabetic DISEASE or
renal diet. She was taking adequate p.o. Her white blood
cell count at discharge was 9.4. Her blood urea nitrogen and
creatinine were 52 and 6.3 with a potassium of 4.8 and
bicarbonate of 21.

At this time her stump which had been resected back to the
level of the proximal one third of the right lower extremity
was clean dry DISEASE and intact with staples in place no erythema DISEASE
no exudate no evidence of hematoma DISEASE and the flaps were warm.
She was deemed stable and appropriate for discharge by Dr.[**Name DISEASE (NI) 4436**] service.

MEDICATIONS ON DISCHARGE:
1. Nephrocaps one tablet p.o. once daily.
2. Vancomycin to be dosed at time of dialysis times two
weeks dose for trough values less than 15.0.
3. Norvasc 5 mg p.o. twice a day.
4. Gabapentin 300 mg q Monday Wednesday and Friday after
hemodialysis.
5. Tramadol 50 mg p.o. twice a day p.r.n.
6. Trazodone 100 mg p.o. q.h.s.
7. Medroxyprogesterone 2.5 mg p.o. once daily.
8. Albuterol MDI q4hours p.r.n.
9. Pantoprazole 40 mg p.o. once daily.
10. Calcitriol 0.25 mcg p.o. once daily to be on hold until
followed up by her nephrologist.
11. Aspirin 81 mg p.o. once daily.
12. Folic Acid 1 mg p.o. once daily.
13. Epogen 20000 units q Monday Wednesday and Friday with
hemodialysis.
14. MSIR 50 mg p.o. q12hours.
15. Dilaudid 2 to 4 mg p.o. q3-4hours p.r.n. breakthrough
pain DISEASE .
16. Colace and Pericolace for stool softening agents.

FOLLOW-UP: The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in
approximately two to three weeks for skin clip removal. She
will have right lower extremity remain in knee immobilizer
with a dry dressing and ace wrap to above knee region to help
immobilize and straighten her leg. She should take part in
aggressive physical therapy and learn how to do transfers and
so forth. Ultimately she will require outpatient sitting for
prosthesis however the stump cannot be used until
designated by Dr. [**Last Name (STitle) 1391**]. Typically this occurs within six
to eight weeks postoperatively. The patient is deemed
appropriate and stable for discharge.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 4417**]

Dictated By:[**Last Name (NamePattern4) 4437**]
MEDQUIST36

D: [**2110-8-30**] 10:13
T: [**2110-8-30**] 10:32
JOB#: [**Job Number 4438**]

cc:[**Last Name (NamePattern1) 4439**]Admission Date: [**2152-9-23**] Discharge Date: [**2152-10-5**]

Date of Birth: [**2075-7-16**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Respiratory distress/hypoxia DISEASE

Major Surgical or Invasive Procedure:
elective intubation [**2152-9-26**]

History of Present Illness:
77 YO old male with PMH significant for DM HTN high chol CAD
s/p stents [**2150**] CHF Afib DISEASE s/p PPM [**2150**] CKD who presents to ED
because of weakness DISEASE and collapse at home. Patient was found on
admission to be febrile tachypneic DISEASE with RUL pneumonia on chest
film. Patient complained of chronic cough DISEASE with increasing sputum
production. He denies fevers chills shortness DISEASE of breath
chest pain DISEASE . He denies any loss of consciousness or head trauma DISEASE
with falls. Denies bowel or bladder incontinence DISEASE or changes in
function. Denies any weight loss DISEASE or changes in eating habits.
No abd pain/n/v/d. No choking DISEASE on food reported.

Patient was admitted and started on ceftriaxone and azithromycin
for CAP which was then changed to Levoflox and Flagyl as CXR
showed Admission Date: [**2180-2-3**] Discharge Date: [**2180-2-13**]

Date of Birth: [**2101-3-2**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Lipitor

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Angina DISEASE

Major Surgical or Invasive Procedure:
Cabg x4 [**2180-2-7**] (LIMA to prox. LAD SVG to distal LAD SVG to
ramus SVG to OM)


History of Present Illness:
78 yo male with history of internmittent angina DISEASE for the past
year relieved by rest. Failed a recent ETT and referred for
cath which revealed LM 50-60% 75% LAD CX 95% OM 3 70% RCA
30% PDA 75%. Referred DISEASE for CABG.

Past Medical History:
MI
CAD s/p angioplasty [**2165**]
HTN DISEASE
elev. chol.

PSH DISEASE : rem. renal calc.
rem. cervical disc [**2154**]

Social History:
Retired: lives alone
50 year history of smoking cigars
Occasional ETOH

Family History:
Non-contributory

Physical Exam:
VS: Wgt: 76.8 kg preop 72.4 HR: 50's SB BP: 104-110/50-60
HEENT unremarkable
Neck supple full ROM no carotid bruits DISEASE appreciated
Resp: decreased breath sounds bilaterally with crackles 1/4 up
on Left
Card: RRR no murmur
GI: bowel sounds positive abdomen soft non-tender/non-distened
Extrem: warm well-perfused no edema DISEASE
Neuro grossly intact
Wound: sternal cleandry intact with staples no erythema DISEASE
Pulses: 2Admission Date: [**2138-11-15**] Discharge Date: [**2138-11-19**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Fatigue DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a [**Age over 90 **] year old male with a recent diagnosis of
prostate cancer DISEASE (he is follwed by Dr. [**First Name4 (NamePattern1) 1313**] [**Last Name (NamePattern1) **] from urology)
who presents with 9-10 days of coughing and generalized
weakness. Patient notes light headedness DISEASE -room spining and
orthostatic symptoms DISEASE over past several days secondary to
decreased po intake. He denies abdominal pain nausea vomiting DISEASE
or diarrhea DISEASE . Pt had some mechanical falls recently secondary to
instability probably secondary to dehydration DISEASE . Three weeks ago
the patient fell on his right ribs. No obvious head trauma DISEASE . No
fevers chills DISEASE or rigors DISEASE at home at home. Patient has lost 15
pounds in the last six months. No BRBPR no melena DISEASE .
*
In ED the patient received ceftriaxone and azitrhomycin along
with 1 L D5NS x 1 L.
*
While in MICU patient was aggressively hydrated and started on
pressors while being maintained on abx. Patient spontaneously
converted to sinus rhythym. He states that his shortness of
breath has improved. Denies cp abd pain DISEASE dyuria. Is having nl
bowel movements DISEASE .

Past Medical History:
Prostate cancer DISEASE - per pt and daughter no [**Name2 (NI) **] diagnosed by serum
but pt cannot recall numbers Admission Date: [**2174-1-4**] Discharge Date: [**2174-2-2**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
hip fracture DISEASE and subsegmental PE

Major Surgical or Invasive Procedure:
L HIP ORIF

History of Present Illness:
[**Age over 90 **] year old female with h/o hypothyroidism anemia DISEASE
osteoporosis DISEASE multiple falls including [**2-20**] and [**3-23**] [**5-23**] who
presents [**1-4**] s/p fall on left hip. Per ambulance report pt was
behind her apartment door with walker when her physical
therapist opened the door which hit her causing her to fall.
She landed on left hip. She denies LOC dizziness palpitations DISEASE
and confusion DISEASE . X-ray confirmed L hip fracture DISEASE .
.
Pt taken to OR [**1-6**] for L ORIF. Intraoperatively she dropped her
O2 sats from 100 to 90 and was noted to have an elevated A-a
gradient. Hip procedure went well without complications.
Post-operatively the pt left ventilated on SIMV and ortho
requested transfer to MICU for further evaluation and treatment.



Past Medical History:
Frequent falls [**4-21**] [**11-21**]
GERD
Hypothyroidism DISEASE
Hearing loss DISEASE on Left
B12-deficiency Iron deficiency Anemia DISEASE
osteoporosis DISEASE
T3 compression fracture DISEASE
UTI DISEASE
Anxiety DISEASE
ECHO [**11-21**] EFAdmission Date: [**2129-7-7**] Discharge Date: [**2129-7-12**]

Date of Birth: [**2086-10-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Ibuprofen / Ace Inhibitors / Bupropion / Zoloft / Aspirin

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
GI bleed DISEASE

Major Surgical or Invasive Procedure:
Sigmoidoscopy

History of Present Illness:
Patient is a 42yo male with history of CAD s/p stents x 3
admitted with acute GI bleed DISEASE .
.
Patient reports being in his normal state of health until this
evening when he developed sudden onset of BRBPR. It occurred
around 9pm. He was taken to the ED by his parents where he
continued to have lower GI bleed DISEASE . He has never had a GI bleed DISEASE
before. Pt denied abd pain DISEASE and n/v no hematemesis DISEASE
coffee-ground emesis DISEASE or melena DISEASE . Patient states he has on and off
suprapubic pain DISEASE for the past year and that he has frequent
constipation DISEASE with straining and painn with bowel movements DISEASE .
Of note he is on aspirin and plavix for coronary stent
placement.
.
In the ED initial vs were: T- 98.0 HR- 118 BP- 184/157 RR-
18 SaO2- 98% on RA DISEASE . Patient was initially given 250cc NS but
had persistent tachycardia DISEASE and developed lightheadedness DISEASE . He was
then give 3U PRBC and 2L NS with resolution of the tachycardia DISEASE .
He never became hypotensive DISEASE or had a fever DISEASE . Abdominal exam was
benign. Rectal exam showed bright red [**First Name3 (LF) **]. NG lavage was
negative. EKG was unchanged from prior. Hct on admission to ED-
45.8 (with normal coags). Patient lost about 1L of [**First Name3 (LF) **] from GI
tract.
.
GI was consulted and recommended angiogram with embolization as
they were concerned for diverticulosis DISEASE vs AVM DISEASE . General surgery
was also made aware of the patient and are available if needed.
IR-team notified and will be coming in tonight to perform
embolization if needed.
.
On the floor he remained hemodynamically stable. Vitals on
transfer: BP- 126/87 HR- 88 SaO2- 98% on RA DISEASE RR- 12 and
afebrile. Patient lost another 100cc DISEASE of [**First Name3 (LF) **] on arrival to the
floor but remained hemodynamically stable. He denied any
nausea/vomiting chest pain shortness of breath dizziness DISEASE
lightheadedness. He did report some lower abdominal tenderness DISEASE
to palpation (LAdmission Date: [**2160-12-15**] Discharge Date: [**2160-12-24**]


Service: MEDICINE

Allergies DISEASE :
Ibuprofen / Percocet / Naprosyn / Percodan

Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
Valvuloplasty

History of Present Illness:
[**Age over 90 **] yo female with 3VD CAD s/p MI in [**2156**] POBA LCX CHF DISEASE with EF
25% with worsening RV function dyslipidemia HTN rheumatic DISEASE
heart disease AV stenosis DISEASE s/p valvuloplasty x2 with recent CHF DISEASE
exacerbation c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Patient had been doing well at rehab.
Bumex was restarted [**12-12**]. Last night developed SOB and was sent
to [**Hospital **] Hosp ER where they felt she was hypovolemic DISEASE and
treated with 2L IVF and sent her back to [**Location (un) **]. This am the
patient experienced worsening SOB. She was treated with
Morphine Bumex 1mg x 2 and [**2-2**] of a 1/150 SL nitro x 2 b/c pt
c/o chest tightness DISEASE . After taking nitro the pt's BP dropped to
90/s the later returned to baseline 100s. At time of transfer
her O2 sat was 94% on 2Lnc but will dip down to 88% with talking
or sips of water.
.
On the floor the patient was complaining of dry mouth DISEASE and thirst DISEASE
and drinking water. She denied SOB chest pain DISEASE or any other
discomfort. She denies cough fever chills DISEASE . However she stated
she had had some delirium DISEASE at the rehab due to double dose of
morphine but was unclear about the exact events. She is aware
that she is at [**Hospital1 **].
.
The patient has severe aortic stenosis DISEASE with low output (EF Admission Date: [**2175-1-28**] Discharge Date: [**2175-3-4**]


Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
aspiration pneumonia DISEASE

Major Surgical or Invasive Procedure:
G-J tube replacement
PICC line placement


History of Present Illness:
Patient is a [**Age over 90 **] year old man with a long history of a persistent
vegetative state recently admitted to [**Hospital1 112**] with an aspiration
pneumonia DISEASE . He required intubation and was maintained on TPN and
tube feedings until he was able to be extubated and discharged
to rehab. He returns after only a few days after a presumed
episode of reaspiration again requiring intubation and pressor
support.

Past Medical History:
-Alzheimer disease
-persistent vegetative state
-GERD
-h/o aspiration PNA
-osteopenia
-atrial fibrillation DISEASE
-myoclonus

Social History:
Has been cared for by his daughter for the past three years.

Family History:
Noncontributory

Physical Exam:
Gen unresponsive resting comfortably
Neck flexed with no masses
CV RRR no m/r/g
Resp coarse BS bilaterally
Abd mildly distended slightly firm GJ tube in place
Ext [**12-19**]Admission Date: [**2188-5-9**] Discharge Date: [**2188-5-14**]

Date of Birth: [**2121-7-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Direct transfer from [**Hospital3 417**] Hospital for STEMI cath and
now stablized hct and transfered out of CCU

Major Surgical or Invasive Procedure:
Cardiac catheterization
Blood transfusion

History of Present Illness:
Mr. [**Known lastname 2391**] is a 66-year-old male with hx HIV on HAART
lymphoma LUL lung adenocarcinoma DISEASE s/p resection hx CAD s/p PCI
with DES in [**5-17**] to proximal circumflex artery. In [**11-16**] he had
elective cath showing 90% restenosis DISEASE at proximal edge of
previously placed stent treated with overlapping Cyper stent.
Mid-RCA was 80% occluded and treated with DES as well. In [**2-18**]
pt had a left femoral artery to dorsalis pedis artery bypass
graft with an in situ greater saphenous vein graft. His plavix
was discontinued at that time. He was recently admitted on
[**2188-4-30**] w/ STEMI over III F taken to cath where he had a DES
placed in the LCX for the vessel being occluded by a thrombus DISEASE
proximally. Of note at cath [**4-30**] he had a totally occluded
right external iliac artery. The pt was discharged home [**2188-5-3**].
Since that time per the pt he felt at baseline with the
exception of intermittent left leg pain DISEASE (s/p vascular surgery
bypass) that would occasionally awaken him at night. He stated
he was up this morning at 4am b/c of this left leg pain DISEASE when he
developed a Admission Date: [**2175-3-10**] Discharge Date: [**2175-5-10**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Aspiration

Major Surgical or Invasive Procedure:
Intubation repostitioning G-Tube change of G-tube to G-J tube

History of Present Illness:
Mr. [**Known lastname 4476**] is a [**Age over 90 **] year old man with a long history of
end-stage dementia DISEASE for at least 10 years with recurrent
aspiration pneumonias DISEASE and pressure ulcers DISEASE who presents to the
[**Hospital1 18**] ED from [**Hospital **] Rehab with an aspiration. He was recently
discharged from [**Hospital1 18**] [**3-3**] after he had an aspiration and had a
prolonged intubation. He was treated with vanc/zosyn for a two
week course which was completed [**3-5**]. Today nursing at [**Hospital1 **]
noted that his abdomen was somewhat distended. A KUB was
performed that showed the feeding tube was coiled in his stomach
in a different position. Tube feeds were restarted and the
feeding tube was noted to be further displaced with the phlange
out of place. The patient was turned and began vomiting DISEASE and
gagging DISEASE and was suctions. His VS when he was evaluated there
were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM DISEASE .
.
The patient was brought to the [**Hospital1 18**] ED evaluation. In the ED
he was immediately intubated and started on
levaquin/vanc/flagyl for presumed aspiration pneumonia DISEASE . He
transiently dropped his blood pressure to a systolic of 80's
over 30's and was started on levophed.


Past Medical History:
End-stage Alzheimers
Atrial fibrillation DISEASE
Recurrent aspiration pneumonias DISEASE
h/o MRSA and VRE colonization
Myoclonus DISEASE


Social History:
Recently discharged from [**Hospital1 18**] to [**Hospital **] rehab.
Has been cared for by his daughter for the past three years.


Family History:
Noncontributory

Physical Exam:
VS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat
98%
Vent: AC Tv 500 RR 14 PEEP 8 FiO2 60%
GEN: unresponsive intubated man on a intubated and sedated on a
ventilator
HEENT: Dry MM sclerae anicteric DISEASE pinpoint pupils.
CV: Distant heart sounds irregular
PUL: Coarse rhonchi DISEASE throughout
ABD: Distended no rebound or guarding.
EXT: 1Admission Date: [**2116-12-14**] Discharge Date: [**2116-12-25**]

Date of Birth: [**2037-1-21**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Weakness for one week

Major Surgical or Invasive Procedure:
RIGHT CRANIOTOMY FOR EVACUATION OF SUBDURAL HEMORRHAGE


History of Present Illness:
79 year old male presents with generalized weakness DISEASE for the
last week. He says that he feels like he has been moving slow
and his wife notes that he has needed help getting dressed and
it
seems like he is dragging his left leg sometimes. He denies any
falls but does note that he sometimes feels like he loses his
balance. No other complaints no history of trauma DISEASE no
headaches DISEASE .
(per admission note)

Past Medical History:
chronic UTIs hypercholesterolemia HTN DISEASE


Social History:
lives with wife denies tobacco or EtOH use


Family History:
n/c

Physical Exam:
PHYSICAL EXAM DISEASE ON ADMISSION:
O: T: 97.1 BP: 126/74 HR: 60 R 16 O2Sats 97% RA DISEASE
Gen: WD/WN comfortable NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft NT BSAdmission Date: [**2107-5-26**] Discharge Date: [**2107-6-9**]

Date of Birth: [**2029-5-6**] Sex: F

Service: SURGERY

Allergies DISEASE :
Cortisone / Percocet / Prednisone / Advair Diskus

Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Abdominal pain DISEASE

Major Surgical or Invasive Procedure:
[**2107-5-26**]: Exploratory laparotomy with ileocolectomy

History of Present Illness:
78F s/p laparoscopic converted to open right hemicolectomy for
Stage 1 (T1N0) right colon cancer DISEASE on [**2106-10-29**] now being
transferred from OSH with diffuse abdominal pain DISEASE and guarding on
exam. She started with diffuse abdominal pain DISEASE at 9am yesterday
and went to [**Hospital3 4485**] at 9pm. She had some nausea DISEASE and
bilious emesis DISEASE x5 but had been passing flatus and bowel
movements. A non-contrast CT was performed and she was sent here
as her abdominal exam was concerning. In ED with A.fib w/RVR
hypertension DISEASE up to 200/100.

Past Medical History:
CAD s/p PCI (last '[**02**]) pAFib CHF HTN DISEASE
hyperchol interstitial lung disease GIB DISEASE GERD CRI (baseline
Cr
1.3-1.8) NIDDM hypothyroid TIA parkinson's DISEASE low back pain DISEASE

Past Surgical History:
Diverting transverse loop colostomy after colonic perforation DISEASE
from colonoscopy colostomy reversal ventral hernia DISEASE repair
with mesh Laparoscopic converted to open right hemicolectomy
[**2106-11-15**].

Social History:
Patient is retired lives at home with husband. Former [**Name2 (NI) 1818**].
Denies alcohol or other drugs.


Family History:
NC

Physical Exam:
On admission:
Vitals: T 101.1 HR 160 BP 120/90 RR 20 SO2 96%
GEN: A&O NAD
HEENT: No scleral icterus mucus membranes moist
CV: RRR No M/G/R
PULM: Clear to auscultation b/l No W/R/R
ABD: Firm nondistended severely tender diffusely mild rebound
tenderness DISEASE and voluntary guarding.
DRE: normal tone no gross or occult blood
Ext: 1Admission Date: [**2110-2-21**] Discharge Date: [**2110-2-24**]

Date of Birth: [**2052-12-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
57 y/o man with a history of aoritc valve replacement [**2102**] [**2-24**]
congenital bicuspid valve DISEASE copd HTN DISEASE prior alcohol abuse who
is admitted to the [**Hospital Ward Name **] ICU with dyspnea DISEASE and transient
hypotension DISEASE .
.
The patient was recently admitted to [**Hospital1 18**] from [**2110-1-28**] to
[**2110-2-2**] for dyspnea DISEASE and was treated for a COPD DISEASE excaerbation with
steroids and azithromycin. An echocardiogram performed during
the admission was normal without significant impairment in
relaxation. He completed his course but continued to have
symtpoms. In fact VNA contact[**Name (NI) **] his PCP (who had not yet met
him) on [**2-13**] with concerns that included continued dyspnea DISEASE a
reported 20lb weight gain DISEASE and lower extremity edema DISEASE . The
patient began 20mg lasix at that time.
.
On presentation to his new PCPs office [**2110-2-21**] he had a
continued oxygen requirment of 3L at rest sating 95% and 90%
with ambulation. The patient endorsed dyspnea DISEASE walking even 30
feet. He was sent to the ED for a rule out of PE. per reports
he was moving air well at that time and did not have wheezing DISEASE .
He had just completed his prescribed steroid taper on [**2-19**] which
was a total of 14 days.
.
On arrival to the ED he was 96.9 124/59 91 24 95%on 3L
In the ED he was given lasix 40mg IV x 1 and a CTA was obtained.
The CTA was negatvie for PE. The lasix dropped his blood
pressure transiently to 75/40 which was response to a total of
2L normal saline challenge. He was not given steroids or
nebulizers. Despite resolution of his hypotension DISEASE he was sent
to the [**Hospital Unit Name 153**].
.
Further review of systemts notable for minimal cough DISEASE no fever DISEASE
and no chest pain DISEASE . He does not occasional paroxysmal abdominal
pain DISEASE for which a RUQ u/s on [**1-28**] was negative for acute
pathology. He notes leg swelling DISEASE for which tight socks have
helped. He also reports difficulty sleeping requiring 3 pillows
at night. He reports that he did not feel completely better
during his hospitlization at [**Hospital1 18**] notable that he did not try
and walk around much. He thinks that his shortness of breath DISEASE has
been much worse since [**2109-12-23**] allthough clearly he must
have marked dysfunction given disability DISEASE [**2-24**] dyspnea DISEASE . Former
patient of [**Hospital1 2177**] and a comprehensive review of old records is not
available at this time.
.


Past Medical History:
# COPD DISEASE - was seen frequently at [**Hospital6 **]. Has
smoked 3 packs /day x 45 years quit on last admission to [**Hospital1 18**].
No PFTs in our system.
# Congential Bicuspid Aortic ValveAdmission Date: [**2112-5-6**] Discharge Date: [**2112-5-12**]

Date of Birth: [**2052-12-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Respiratory distress DISEASE .

Major Surgical or Invasive Procedure:
1. Inubation
2. Placement of central venous access via the right internal
jugular


History of Present Illness:
Mr. [**Known lastname 4509**] is a 59yo M with history of severe COPD DISEASE and pulmonary
hypertension DISEASE who was brought in by ambulance for respiratory
distress. Per report when EMS arrived all of his inhalers were
empty.
.
In the ED initial vs were: T 98.8 P 121 BP 100/67 R 17 O2 sat
100%. He was immediately intubated for respiratory distress DISEASE as
he wasn't able to speak few words. He was on propofol for
sedation. His pressures were in the 90s and dipped to the 80s
so R IJ was placed and levophed was started. CXR showed fluffy
bilateral infiltrates and ABG was significant for hypcarbia DISEASE to
106. He received 125mg IV solumedrol albuterol magnesium
levaquin ceftriaxone and was started on versed/fent drips.
.
In the ICU patient is intubated and sedated.

Past Medical History:
# COPD DISEASE - was seen frequently at [**Hospital6 **]. Has
smoked 3 packs /day x 45 years quit on last admission to [**Hospital1 18**].

No PFTs in our system.
# Congential Bicuspid Aortic ValveAdmission Date: [**2194-7-24**] Discharge Date: [**2194-8-3**]


Service: [**Hospital1 139**] - Medicine and MICU

HISTORY OF PRESENT ILLNESS: This 84-year-old female with a
history of diverticula CREST DISEASE and irritable bowel syndrome DISEASE
presented to the Emergency Room with a chief complaint DISEASE of
epigastric pain lightheadedness nausea DISEASE without emesis DISEASE and
dark stools. She denied chest pain shortness of breath DISEASE
cough fevers chills DISEASE and night sweats. In the Emergency
Room she was found to have a blood pressure of 130/palp with
a heart rate of 72. One hour later this was 119/39 with a
pulse of 100. She had heme positive stool and hematocrit was
found to be 16.6. The patient therefore had an emergent EGD
in the GI unit. No nasogastric lavage was performed.

PAST MEDICAL HISTORY: The patient has Sjogren DISEASE 's with sicca DISEASE
syndrome and presumed CREST DISEASE with a history of dysphagia DISEASE and
dyspepsia DISEASE . The patient's primary gastroenterologist is Dr.
[**Last Name (STitle) 1940**]. Patient has a history of hypertension DISEASE
hypothyroidism irritable bowel syndrome DISEASE with chronic
diarrhea Raynaud DISEASE 's history of TAH DISEASE cholecystectomy and
pericholecystectomy hernia DISEASE repair COPD DISEASE and bronchiectasis DISEASE
right bronchial sclerosis DISEASE and Sjogren DISEASE 's history of bladder
stretchings negative MRCP [**6-18**] except for some liver cysts DISEASE
diverticula DISEASE on colonoscopy [**7-/2193**] with possibility of Crohn DISEASE 's
noted.

SOCIAL HISTORY: The patient smoked some tobacco in the past
but it was a small amount. She drinks no alcohol.

FAMILY HISTORY: Crohn's disease DISEASE .

ALLERGIES: Penicillin Bactrim and Sulfa.

MEDICATIONS: Norvasc 10 mg q d Atenolol 50 mg q d Levoxyl
1.25 mg q d Dyazide 37.5/25 q d Serax prn occasional
NSAIDs Premarin .625 mg q d and Aspirin.

PHYSICAL EXAMINATION: Temperature 97 blood pressure 95/69
respiratory rate 14 satting 100% on two liters. The patient
was alert and oriented times three she was fully conversant
and awake interactive and appropriate. She was in no acute
distress. Conjunctiva were pale. She had dry mucus
membranes. She was normocephalic atraumatic extraocular
movements intact pupils were equal round and reactive to
light. There was no JVD. Neck was supple. TMs were normal.
There was no lymphadenopathy DISEASE of the neck faint bibasilar
crackles were heard on lung exam. The patient was
tachycardic with a normal S1 and S2 with 2/6 systolic
ejection murmur radiating to the axilla. Abdomen was soft
and non distended with normal bowel sounds was mildly tender
to deep palpation. Extremities without clubbing cyanosis DISEASE or
edema DISEASE . Fingers were cool as were the toes but she had 1Admission Date: [**2195-6-17**] Discharge Date: [**2195-7-7**]


Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is an 84 year-old female
with a history of CREST diverticular disease irritable DISEASE
bowel syndrome DISEASE and prior upper GI bleed in [**7-19**] secondary to
AVM DISEASE and gastritis DISEASE . Her previous UGIB DISEASE required
hospitalization which was notable for a hematocrit of 16 on
during stay 2 units of fresh frozen platelets
esophagogastroduodenoscopy showing gastritis DISEASE and normal
duodenum cauterization of a gastric AVM DISEASE and angiography
followed by embolization of left gastric artery.

She presented to the Emergency Room at this time with a chief
complaint DISEASE of two days of dark stools left lower abdominal
breath lightheadedness fevers DISEASE or chills DISEASE and night sweats.
No bright red blood per rectum no hematemesis DISEASE . In the
Emergency Room she was found to be in no acute distress and
with a temperature of 99.5 blood pressure 143/53 pulse 86
respirations 16 98% on room air. Nasogastric suction
revealed 200 cc of coffee grounds and lavage with 250 cc H20
showed coffee grounds and a bright red tinge but lavage was
stopped because of patient discomfort. Central line in
femoral vein was placed and she was given one liter of normal
saline.

PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome DISEASE
CREST DISEASE with a history of dysphagia DISEASE and dyspepsia DISEASE (followed by
gastroenterologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]). 2. Hypertension.
3. Hypothyroidism. 4. Irritable bowel syndrome with
chronic diarrhea constipation DISEASE and abdominal pain DISEASE . 5.
Diverticula seen on colonoscopy [**7-/2193**]. 6. Chronic
obstructive pulmonary disease DISEASE with bronchiectasis DISEASE right
bronchial sclerosis DISEASE . 7. History of bladder stretching.

PAST SURGICAL HISTORY: 1. Cholecystectomy. 2.
Pericholecystectomy hernia DISEASE repair. 3. Hysterectomy.

SOCIAL HISTORY: Three pack years of smoking quit twenty
years ago. Drinks no alcohol.

FAMILY HISTORY: Son has Crohn's disease DISEASE times forty two
years.

ALLERGIES: Penicillin and sulfa.

MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2.
Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid
175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30
mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a
day.

PHYSICAL EXAMINATION: General thin elderly woman in no
acute distress. Vital signs temperature 99.5. Blood
pressure 120/60. Pulse 86. Respiratory rate 18. Skin
normal capillary refill plus telangiectasias DISEASE on the back.
HEENT right ptosis DISEASE . No scleral icterus DISEASE . Pupils are equal
round and reactive to light. Extraocular movements DISEASE intact.
Mucous membranes are dry. No lower dentition. Neck supple.
No lymphadenopathy DISEASE . Jugular veins flat. Chest clear to
auscultation bilaterally. Cardiovascular regular rate and
rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at
right upper sternal border. No gallops or rubs. Abdomen
flat. Scar along right abdomen. Positive bowel sounds
nondistended. No tenderness DISEASE to palpation. No
hepatosplenomegaly DISEASE . Extremities no clubbing cyanosis DISEASE or
edema DISEASE . Fingers and toes cool to touch. 2Admission Date: [**2195-6-17**] Discharge Date: [**2195-7-7**]


Service: [**Hospital1 **]

HISTORY OF PRESENT ILLNESS: This is an 84 year-old female
with a history of CREST diverticular disease irritable DISEASE
bowel syndrome DISEASE and prior upper GI bleed in [**7-19**] secondary to
AVM DISEASE and gastritis DISEASE . Her previous UGIB DISEASE required
hospitalization which was notable for a hematocrit of 16 on
admission 11 units of packed red blood cells transfusion
during stay 2 units of fresh frozen platelets
esophagogastroduodenoscopy showing gastritis DISEASE and normal
duodenum cauterization of a gastric AVM DISEASE and angiography
followed by embolization of left gastric artery.

She presented to the Emergency Room at this time with a chief
complaint DISEASE of two days of dark stools left lower abdominal
pain DISEASE and weakness DISEASE . She denied chest pain shortness DISEASE of
breath lightheadedness fevers DISEASE or chills DISEASE and night sweats.
No bright red blood per rectum no hematemesis DISEASE . In the
Emergency Room she was found to be in no acute distress and
with a temperature of 99.5 blood pressure 143/53 pulse 86
respirations 16 98% on room air. Nasogastric suction
revealed 200 cc of coffee grounds and lavage with 250 cc H20
showed coffee grounds and a bright red tinge but lavage was
stopped because of patient discomfort. Central line in
femoral vein was placed and she was given one liter of normal
saline.

PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome DISEASE
CREST DISEASE with a history of dysphagia DISEASE and dyspepsia DISEASE (followed by
gastroenterologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]). 2. Hypertension.
3. Hypothyroidism. 4. Irritable bowel syndrome with
chronic diarrhea constipation DISEASE and abdominal pain DISEASE . 5.
Diverticula seen on colonoscopy [**7-/2193**]. 6. Chronic
obstructive pulmonary disease DISEASE with bronchiectasis DISEASE right
bronchial sclerosis DISEASE . 7. History of bladder stretching.

PAST SURGICAL HISTORY: 1. Cholecystectomy. 2.
Pericholecystectomy hernia DISEASE repair. 3. Hysterectomy.

SOCIAL HISTORY: Three pack years of smoking quit twenty
years ago. Drinks no alcohol.

FAMILY HISTORY: Son has Crohn's disease DISEASE times forty two
years.

ALLERGIES: Penicillin and sulfa.

MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2.
Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid
175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30
mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a
day.

PHYSICAL EXAMINATION: General thin elderly woman in no
acute distress. Vital signs temperature 99.5. Blood
pressure 120/60. Pulse 86. Respiratory rate 18. Skin
normal capillary refill plus telangiectasias DISEASE on the back.
HEENT right ptosis DISEASE . No scleral icterus DISEASE . Pupils are equal
round and reactive to light. Extraocular movements DISEASE intact.
Mucous membranes are dry. No lower dentition. Neck supple.
No lymphadenopathy DISEASE . Jugular veins flat. Chest clear to
auscultation bilaterally. Cardiovascular regular rate and
rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at
right upper sternal border. No gallops or rubs. Abdomen
flat. Scar along right abdomen. Positive bowel sounds
nondistended. No tenderness DISEASE to palpation. No
hepatosplenomegaly DISEASE . Extremities no clubbing cyanosis DISEASE or
edema DISEASE . Fingers and toes cool to touch. 2Admission Date: [**2196-5-13**] Discharge Date: [**2196-5-16**]


Service:

CHIEF COMPLAINT: GI bleed transfer from [**Hospital3 4527**].

HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
woman with a history of Sjogren syndrome DISEASE with sicca syndrome DISEASE
and also CREST DISEASE with predominant Raynaud DISEASE 's history of GI
bleed DISEASE in the past thought secondary to gastritis DISEASE and
arteriovenous malformations DISEASE status post left gastric and
left gastroduodenal artery embolizations in [**7-18**] and [**6-18**]
respectively. She presented to [**Hospital3 4527**] in mid-[**2196-4-17**] with bright red blood per rectum and an hematocrit drop
from 34 to 28. Her work-up at that time consisted of an
abdominal CT that revealed a pancolitis DISEASE increased
splenomegaly DISEASE and new ascites DISEASE . She was transfused two units
and discharged to rehabilitation on [**2196-5-7**] and then two to
three days prior to admission the patient noted dark stools
and on the morning prior to admission the patient had nausea DISEASE
decreased appetite and an episode of vomiting DISEASE bright red
blood. She subsequently went to [**Hospital3 4527**] on [**2196-5-12**]
in the morning. In the emergency room there her systolic was
in the 90s hematocrit was 18 down from 28 on discharge.
Her INR was 1.7. She had a left IJ triple-lumen catheter
placed a right EJ peripheral line and she subsequently
underwent EGD which revealed grade 0-1 esophageal varices
portal gastropathy gastric varices DISEASE but no active bleed DISEASE
although there were multiple blood clots in the stomach. She
was treated with IV Protonix and was started an octreotide
drip. She was transfused several units which improved her
hematocrit from 18 to 28 and then on the morning of the 27th
around 1 AM she had a repeat episode of hematemesis DISEASE and
nasogastric lavage did not clear after two liters of saline.
An emergency EGD was performed that revealed a large varix DISEASE at
the gastroesophageal junction and there was blood in the
fundus. Sclerotherapy was attempted which resulted in an
initial blood spurt however the bleeding DISEASE subsequently
stabilized and overall during the resuscitative efforts she
was given six units of red cells and four units of fresh
frozen plasma and she was transferred to [**Hospital1 346**] for evaluation of emerging TIPS.

Here in the intensive care unit the patient was comfortable
with no nausea DISEASE or vomiting DISEASE no further hematemesis DISEASE . She
denied any abdominal pain DISEASE .

PAST MEDICAL HISTORY: 1. Sjogren DISEASE 's with sicca syndrome DISEASE . 2.
CREST DISEASE with predominant Raynaud DISEASE 's. 3. History of GI bleed DISEASE
status post left gastric artery embolization in [**7-18**] and
left gastroduodenal artery embolization in [**6-18**]. 4. History
of pancolitis DISEASE . 5. Recent episode of bleeding DISEASE points. 6.
Irritable bowel syndrome DISEASE . 7. Hypertension DISEASE . 8. Hashimoto DISEASE 's
hypothyroidism DISEASE with positive antibody. 9. Diverticulosis.
10. History of left femoral DVT DISEASE in [**6-18**]. 11. History of
chronic obstructive pulmonary disease/bronchitis DISEASE .

MEDICATIONS: 1. Octreotide drip at 50 mcg per minute. 2.
Protonix 40 IV b.i.d. 3. Ativan p.r.n. 4. Atrovent
albuterol nebulizers. 5. Vitamin K subcutaneous x 3.

ALLERGIES: The patient is allergic DISEASE to sulfa and penicillin.

SOCIAL HISTORY: The patient lives in [**Location (un) 4528**] skilled
nursing facility. Her son lives locally daughter is on the
west coast. Minimal alcohol history and remote tobacco. The
patient has a son with [**Name (NI) 4522**] disease.

PHYSICAL EXAMINATION: On arrival her temperature was 98
blood pressure 160/80 heart rate 80s respiratory rate 16
saturating 95% on two liters. General: She was a
well-appearing elderly frail woman. HEENT: She had
crusted blood in her oropharynx. Pupils equal round and
reactive to light. Sclerae anicteric. Neck: Supple with
no lymphadenopathy DISEASE . Chest: Examination revealed decreased
breath sounds at the left base and bronchial breath sounds DISEASE at
the right base. Cardiac: There was a [**12-24**]
crescendo/decrescendo systolic murmur DISEASE at the right upper
sternal border without radiation. Abdomen: Benign positive
bowel sounds nontender. There was no fluid wave. No liver
edge was appreciated. Extremities: There was no peripheral
edema DISEASE . Skin: There was no jaundice DISEASE notable. Neurologic:
The patient was alert and oriented x 3 otherwise nonfocal.

LABORATORY DATA: On the morning of admission white count was
10.8 hematocrit 31.9 which had been up from 22 earlier in
the morning platelet count 68 which was around her
baseline SMA-7 was unremarkable. BUN and creatinine were
normal. INR was 1.3. PT 14.1 PTT 32.8 fibrinogen was 161
albumin 3.2. ALT AST and alkaline phosphatase were within
normal limits. Total bilirubin was 2.1. Urinalysis on the
morning of arrival had been negative.

EKG showed sinus tachycardia DISEASE at [**Street Address(2) 4529**] depressions in 2
3 aVF V4 to V6 but no acute change compared to old.

HOSPITAL COURSE: 1. Upper GI bleed/variceal bleed: Patient
was thought to have cirrhosis DISEASE of unclear etiology with new
ascites DISEASE and new splenomegaly DISEASE on recent abdominal CT and on
endoscopy at the outside hospital portal gastropathy DISEASE and
esophageal varices DISEASE were found. The patient was initially
transferred to [**Hospital1 69**] for
evaluation for emerging TIPS. The patient had a type and
cross with four units of red cells and fresh frozen plasma on
hold. She had a central line in her left neck as well as a
right EJ. She was continued on octreotide drip at 50 mcg per
hour. She was continued on Protonix 40 IV b.i.d. Her
coagulopathy DISEASE her hematocrit and platelet count were
corrected with products as needed. The patient was evaluated
by the liver team who felt that given her comfortable status
and high risk of precipitating encephalopathy DISEASE TIPS would not
be the best strategyAdmission Date: [**2193-8-5**] Discharge Date: [**2193-8-7**]

Date of Birth: [**2118-7-9**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
s/p VF arrest DISEASE

Major Surgical or Invasive Procedure:
A-line placement

History of Present Illness:
75 yo female with DM DISEASE presenting with VF arrest DISEASE . Per patient's
husband patient was at home with her husband this morning.
Husband was outside walking the dog and when he walked in heard
his wife call out for him then heard her collapse. He was at
her side immediately could not feel a pulse. He gave her
glucagon as she has a history of hypoglycemia DISEASE with no effect.
He called 911 within 5-10 minutes of finding her down. 911
responded within 2 minutes and defibrillated immediately. She
received three rounds of epinephrine intubated and started on
dopamine gtt.
.
Initial vital signs in ED were HR 120 BP 75/p. EKG showed afib
with rate [**Street Address(2) 4531**] depressions DISEASE in V1-V5. Initial labs showed
no leukocytosis DISEASE normal hematocrit and were significant for a pH
of 7.17 lactate of 8.8 bicarb of 16 and glucose of 178.
Patient was given a lidocaine bolus and started on a drip. She
was also given levophed for further pressure support in addition
to dopamine drip. She was seen by cardiology and given an
amiodarone bolus and drip for rate control. Post cardiac arrest DISEASE
hypothermia DISEASE protocol was initiated.
.
On arrival to the CCU patient's VS were HR90 in SR with
frequent PVCs BP 111/55 on levophed (dopamine was discontinued
prior to transfer).
.
According to husband patient had no recent complaints of chest
pain shortness of breath orthopnea DISEASE or paroxysmal nocturnal
dyspnea DISEASE . She has known cardiac history. She is a type I
diabetic DISEASE and has neuropathy DISEASE and diabetic retinopathy DISEASE . She is
legally blind.


Past Medical History:
1. CARDIAC RISK FACTORS: Type I diabetes
2. CARDIAC HISTORY:
- None.
3. OTHER PAST MEDICAL HISTORY:
- Type I diabetes
- Glaucoma
- Diabetic neuropathy
- Diabetic retinopathy legally blind

Social History:
Lives with husband who was an ophthalmologist. Active in
community. No children.
- Tobacco history: Never
- ETOH: Occasional
- Illicit drugs: Denies

Family History:
Non contributory

Physical Exam:
Admission Physical Exam:
VS: TAdmission Date: [**2194-1-7**] Discharge Date: [**2194-2-2**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered Mental Status and hypotension DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **]F Russian-speaking h/o refractory nodular sclerosing Hodgkins
Lymphoma DISEASE was brought in by EMS and admitted after her home
health care aide noted she was hypotensive DISEASE to 88/40 and
confused.

In the ED T 98.4 (rectal) HR 101 BP 102/53 RR 20 O2Sat 98%
on 3L. Incontinant of guaiac-positive stool. Treated with 4 L
NS vanco 1g IV ceftazadime 1g IV and flagyl 500mg IV.
Received 0.5 mg ativan and 2mg IV morphine for agitation DISEASE .

Pt was admitted to [**Hospital Unit Name 153**] where she completed a 10-day course of
ceftazadime and vancomycin for urosepsis DISEASE . A 7-day course of
metronidazole was also completed for empiric treatment of C.
Diff given loose stools in the setting of an elevated WBC count
although all C. Diff assays were negative. Pt was stabilized and
was transferred to the floor for further care. At the time of
transfer active issues were poor nutritional status
thrombocytopenia DISEASE and anemia DISEASE .

On the floor however pt experienced an episode of new Afib DISEASE
with RVR to 160s and hypotension DISEASE to SBP 90-100s as well as
respiratory distress DISEASE after she received fluid resuscitation.
There was also a concern for tachy-brady DISEASE syndrome because she
had pauses up to 4 sec on telemetryAdmission Date: [**2157-5-16**] Discharge Date: [**2157-5-21**]

Date of Birth: [**2088-4-1**] Sex: F

Service: UROLOGY

Allergies DISEASE :
Aspirin / Motrin / Trilisate / Naprosyn / Toradol / Vicodin /
Percocet / Indocin / Dilaudid / Zomig

Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
Kidney stone DISEASE

Major Surgical or Invasive Procedure:
Left pyeloscopy with laser lithotripsy and stent exchange
[**2157-5-16**] Dr. [**First Name (STitle) **]
Flexible sigmoidoscopy [**2157-5-20**] GI service.
PICC [**2157-5-21**]


History of Present Illness:
Ms. [**Known lastname **] is a 69-year-old female
who presented in [**Month (only) 958**] with an obstructing 5-mm left UPJ
stone with mild hydronephrosis DISEASE . She was managed at that time
with stent placement and delayed stone management given acute
diverticulitis DISEASE at that time. The patient presented on admission
for
definitive stone management and she elected to undergo
ureteroscopy with laser lithotripsy and stent change. Of
note on preoperative testing she had a white count of 19.0.
Given concern for diverticulitis DISEASE she was given ceftriaxone
and Flagyl before the time of surgery and was scheduled to be
admitted for observation.


Past Medical History:
NIDDM HTN hypercholesterolemia DISEASE

Incisional ventral hernia DISEASE repair [**5-16**]
TAH DISEASE '[**30**]
R knee arthroscopy


Social History:
non-contributory


Family History:
non-contributory

Physical Exam:
Discharge Exam:
AVSS
Gen: NAD
CV: RRR
Resp: CTA-B
Abd: obese s/nt/ndAdmission Date: [**2145-11-14**] Discharge Date: [**2145-11-18**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Found Down DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **] yo male with chronic kidney disease DISEASE who presents to the ED
after being found down at apt. Pt found by landlord after not
being seen in 2 days and found in own feces.
.
ED: While in the ED found to have K of 7 creat of 10 trop of
3 with nl CK. Received 10 U Insulin/ 1 amp D 50 Haldol/ativan
Kayexalate PR Calcium gluconate 1 g x 2. Patient pulled foley
catheter and NGT was unable to be placed.
.
When arrived on MICU floor patient agitated and not responsive
to questions. Withdraws to pain DISEASE .

Past Medical History:
1. Hypertension DISEASE .
2. Chronic renal insufficiency DISEASE (with a baseline creatinine
of 4 documented as far back at [**2140**]). The patient has
refused a workup for this in the past.


Social History:
Patient living alone wife in rehab/[**Hospital1 1501**]. Per OMR: He is a former
[**Company 2318**] worker. He use to drink heavily in his youth. No alcohol at
all in the last 10
years. No tobacco.


Family History:
NC

Physical Exam:
t 97 BP 122/71 RR 19 02 91-100% HR 111
GEN: Arousable agitated
HEENT: MM dry DISEASE PERRL EOMI
Neck: JVP 6 cm
CV: RRR [**2-15**] murmur at LLSB
Pulm: occ exp wheezes otherwise clear bilaterally
Abd: Admission Date: [**2164-10-1**] Discharge Date: [**2164-10-4**]


Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
intubation
central line placement


History of Present Illness:
History of Present Illness: 88F w/ h/o Grave's disease DISEASE
Admission Date: [**2172-7-3**] Discharge Date: [**2172-7-13**]


Service: MED

Allergies DISEASE :
Amoxicillin / Aspirin / Clindamycin / Erythromycin Base /
Bactrim

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
confusion DISEASE

Major Surgical or Invasive Procedure:
EGD

Brief Hospital Course:
Respiratory failure DISEASE : The patient was
intubated and maintained on pressure support ventilation from
the time of admission due to respiratory failure DISEASE with blood
gas consistent with hypoxia DISEASE . Respiratory failure DISEASE in this
patient was presumably due to impending hemodynamic collapse.
There was no clear evidence of pneumonia DISEASE or other primary
pulmonary process on chest x-ray or on examination. The
patient had small right pleural effusion DISEASE on admission and
developed left pleural effusion DISEASE during her hospital stay but
these effusions DISEASE were small and unlikely to contribute to
respiratory distress DISEASE . The patient was maintained on pressure
support ventilation during her admission and oxygenation was
maintained with acceptable parameters.

Hypotension DISEASE : The patient was hypotensive DISEASE on admission with
blood pressure as low as 60 over palpation in the emergency
department. This was most likely secondary to GI bleedAdmission Date: [**2146-7-21**] Discharge Date: [**2146-7-26**]


Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms. [**Known lastname 4549**] is a [**Age over 90 **] y/o female with CAD/ CHF DISEASE afib diabetes DISEASE
presenting from clinic with dyspnea DISEASE :

[**2146-5-30**]: corneal transplant.
10 days ago: increasing dyspnea/ orthopnea DISEASE
5 days ago: Markedly worse dyspnea DISEASE and chills DISEASE can no longer
walk without dyspnea DISEASE .
1 day ago: shoulder pain DISEASE relieved with lidocaine.

At her baseline she is legally blind and ambulates with a caneAdmission Date: [**2139-6-3**] Discharge Date: [**2139-6-7**]

Date of Birth: [**2059-2-14**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Sulfonamides / Quinine / Chloramphenicol

Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
urosepsis DISEASE

Major Surgical or Invasive Procedure:
central line placement and removal

History of Present Illness:
This is an 80 y/o male with a h/o mental retardation GERD c/b
severe erosive esophagitis prostate DISEASE CA s/p TURP without
additional treatment who presented to the ED with fever DISEASE to 103
subjective dyspnea foul smelling DISEASE urine and hypotension DISEASE with
SBPs in the 70s. Pt is not communicative at baseline but did
report lower abdominal pain DISEASE denied any CP SOB cough DISEASE . Pt
otherwise not able to give a more detailed history due to
baseline mental retardation.
.
In [**Name (NI) **] pt was hypotensive febrile DISEASE to 103. His lab values were
notable for an elevated WBC at 18.5 elevated transaminases
elevated lactate at 7.6 and an elevated Cr to 1.9. He was given
5L NS and after placing a R femoral CVL started on Levophed
for BP support. He was empirically started on broad spectrum
antibiotics of vancomycin levofloxacin and flagyl and admitted
to the ICU for further care.
.
In the ICU patient transiently required levaphed for pressure
support. Infectious work up included blood cultures which are
NGTD CXR which was negative RUQ U/S which was negative and
urine culture with was positive for e. coli fluoroquinolone
sensitive. He was maintained on vancomycin levofloxacin and
flagyl. On this regimen the patient stablized as his BP
returned and levophed was discontinued his WBC decreased his
fever DISEASE resolved. His renal failure DISEASE also resolved with fluid
rescusitation. His LFTs trended down. His lactate came down.
.
His ICU course was otherwise notable for a transient episode of
atrial fibrillation DISEASE which was broken with lopressor 5mg IV x 1
and the patient was subsequently started on lopressor 12.5mg
[**Hospital1 **].
.
His course thus far was also notable for platelets decreased
from 130 -Admission Date: [**2131-6-1**] Discharge Date: [**2131-6-15**]


Service: CSU DISEASE


CHIEF COMPLAINT: Increasing fatigue DISEASE decreasing appetite and weight loss DISEASE .

HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is an 81-year-old woman
with multiple episodes of congestive heart failure DISEASE with known
significant mitral regurgitation DISEASE and chronic atrial
fibrillation DISEASE (on Coumadin for her atrial fibrillation DISEASE )
admitted preoperatively to come off of her Coumadin and be
placed on IV heparin while awaiting her INR to come back to
normal levels.

The patient underwent a cardiac catheterization in [**2131-6-20**] which showed a cardiac index of 1.4 30% to 60% RCA
lesion 4Admission Date: [**2131-6-1**] Discharge Date: [**2131-6-15**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Heparin Agents

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mitral regurgitation DISEASE

Major Surgical or Invasive Procedure:
1. Mitral valve replacement (#27 mosaic)


History of Present Illness:
81F c mitral regurgitation DISEASE by TEE with symptoms of increasing
fatigue DISEASE decrease mobility weight loss DISEASE . Evaluated as
outpatient with echo showing mild AI mod MR mild MS mod TR
dilated LA and EF 40% and cardiac cath showing no significant
CAD. She was admitted for preop heparin gtt.

Past Medical History:
1. MR
2. AI
3. HTN DISEASE
4. COPD DISEASE
5. Hypercholesterolemia DISEASE
6. Paroxysmal afib
7. h/o L retinal artery occlusion DISEASE
8. Pulmonary HTN DISEASE
9. s/p TAH DISEASE for endometrial CA

Social History:
Noncontributory

Family History:
Noncontributory

Physical Exam:
Afebrile VSS
NAD alert
Neck: no bruits DISEASE no JVD
Heart: Irregular [**2-25**] murmur
Lungs: CTAB
Abd: soft NT ND Admission Date: [**2118-12-1**] Discharge Date: [**2118-12-3**]

Date of Birth: [**2037-12-24**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
weakness DISEASE and cough DISEASE


Major Surgical or Invasive Procedure:
None

History of Present Illness:
80 yo M with PMH of HTN congenital deafness DISEASE and osteoporosis DISEASE
who presents with fevers cough DISEASE and weakness. History is taken
from patient and his home caregiver and also his HCP by phone.
.
Patient was recently admitted after a fall and found to have a
C7 fracture DISEASE . He was placed in a [**Location (un) 2848**] J collar and returned to
rehab. Per his caregiver over the last two days he has become
more weak (not using his walker but requiring a wheelchair to
get around) coughing and sounded Admission Date: [**2157-3-29**] Discharge Date: [**2157-4-8**]

Date of Birth: [**2074-4-2**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Subdural Hematoma DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
82F w/ h/o multiple myeloma peripheral neuropathy DISEASE recently
hospitalized on neuro service for work-up of multiple falls
transferred from [**Hospital3 2783**] with dx of right SDH. The
patient was found down awake in the afternoon by staff at
nursing home where she lives. She was admitted at [**Hospital1 18**] about 2
weeks ago to work up the falls and at that time had negative
intracranial imaging (see detailed neurology note from [**2157-3-15**]).
The falls were thought to be due to a combination of neuropathy DISEASE
post chemotherapy and mild cervical spondylosis DISEASE and she was
discharged to a nursing home. The current fall was unwitnessed DISEASE
and it is not clear if there was any LOC. Patient denies any
dizziness lightheadedness vertigo nausea/vomiting DISEASE . She also
comes with a new dx of PNA possible aspiration PNA and was
treated with levaquin at OSH prior to arrival.

.

In the ED initial vs were: T98.1 HR 80 BP 104/56 RR 14-16
O2 99%RA. Patient was alert but somewhat confused. Head CT
showed no interval change in mid-line shift or size of SDH.
Neurosurgery recommended 6-pack of plt's DDAVP Vit K (10mg IV)
and 2L NS. Patient also received CTX for finding of pneumonia DISEASE
on CXR. Was admitted to MICU for q1H neuro checks and treatment
of pneumonia DISEASE . At time of transfer VS 97.8 HR 80 Bp 96/41 RR
22 O2 97% 3L NC RA sat of 93-94%


Past Medical History:
1. Multiple myeloma DISEASE s/p chemotherapy followed by Dr. [**First Name (STitle) 2856**]
at [**Company 2860**]. Seen by oncology for decreased counts on last admit
and recommended to receive pulse steroids.

2. HTN DISEASE

3. Peripheral neuropathy DISEASE due to chemotherapy

4. s/p both hips knees replacement and L ankle surgery

5. OA

6. s/p cholecystectomy

7. s/p hysterectomy

8. Frequent falls


Social History:
SH: Was living alone until recent falls with subdural requiring
rehab - does not drive but pays own bills takes own meds and
etc. Used to be a waitress. Has 2 grown children. No
cigarettes or EtOH.



Family History:
FH DISEASE : NC



Physical Exam:
T97.3 HR 84 BP 92/60 O2 Sat 97% 3L NC
General Appearance: No acute distress Thin very pleasant and
comfortable appearing

Eyes / Conjunctiva: PERRL

Head Ears Nose Throat: Normocephalic

Cardiovascular: (S1: Normal) (S2: No(t) Normal Loud) No(t)
S3 No(t) S4 No(t) Rub (Murmur: Systolic) At Erb's point

Peripheral Vascular: (Right radial pulse: Present) (Left radial
pulse: Present) (Right DP pulse: Present) (Left DP pulse:
Present)

Respiratory / Chest: (Expansion: Symmetric) (Breath Sounds:
Crackles : bilaterally)

Abdominal: Soft Non-tender Bowel DISEASE sounds present No(t)
Distended No(t) Tender: No(t) Obese

Extremities: Right: Absent Left: Absent

Skin: Not assessed

Neurologic: Attentive Follows simple commands Responds to:
Verbal stimuli Oriented (to): place knows why she is in
hospital Movement: Purposeful No(t) Sedated No(t) Paralyzed
Tone: Normal [**6-7**] full strength in UE bilaterally diminished
strength 4/5 b/l in LE and nml cranial nerves


Pertinent Results:
[**2157-3-28**] 09:20PM PT-15.1* PTT-33.5 INR(PT)-1.3*
[**2157-3-28**] 09:20PM WBC-16.6*# RBC-2.69* HGB-9.2* HCT-25.5*
MCV-95 MCH-34.3* MCHC-36.1* RDW-19.7*
[**2157-3-28**] 09:20PM ALT(SGPT)-23 AST(SGOT)-41* ALK PHOS-67 TOT
BILI-1.6*
[**2157-3-28**] 09:39PM LACTATE-1.2

[**3-28**] CT Head:
IMPRESSION: Acute on chronic right subdural hematoma DISEASE unchanged
in comparison
study from five hours prior. 1-2mm of leftward shift of normally
midline
structures.

[**3-29**] CT Head:
Evolution of acute-on-chronic right subdural hematoma DISEASE with
posterior layering of the acute component now tracking along
the tentorium. There is no evidence for new hemorrhage DISEASE
increased mass effect or edema DISEASE .

[**4-2**] CT Head:
There has been not significant change in size of an acute on
chronic subdural hematoma DISEASE but evolution of blood products
within the
hematoma DISEASE is seen. There is no shift of minimal mass effect on
subjacent right occipital gyri remains seen and sulci are
unchanged in configuration. The sulci are otherwise prominent
compatible with age-related involution. The ventricular
configuration is unchanged. Again seen is scattered
periventricular white matter hypodensities DISEASE consistent with
chronic microvascular ischemia DISEASE .

Surrounding soft tissues and osseous structures are stable in
appearance.
There is no fracture DISEASE . Imaged paranasal sinuses and mastoid air
cells are well aerated.

IMPRESSION: Evolution of right subdural hematoma DISEASE without
evidence for new
hemorrhage DISEASE or increased mass effect. No new hemorrhage DISEASE .

[**3-28**] CT C-spine DISEASE :
1. No fracture DISEASE or prevertebral soft tissue swelling DISEASE .
2. Multilevel degenerative changes predominantly at C5-6 and
C6-7 unchanged in comparison to MRI [**2157-3-18**].

[**3-28**] Echo:
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-15mmHg. Left ventricular wall thickness cavity
size and regional/global systolic function are normal (LVEF
Admission Date: [**2124-7-21**] Discharge Date: [**2124-8-18**]


Service: MEDICINE

Allergies DISEASE :
Amlodipine

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
COPD DISEASE exacerbation/Shortness of Breath

Major Surgical or Invasive Procedure:
Intubation
arterial line placement
PICC line placement
Esophagogastroduodenoscopy


History of Present Illness:
87 yo F with h/o CHF COPD DISEASE on 5 L oxygen at baseline
tracheobronchomalacia DISEASE s/p stent presents with acute dyspnea DISEASE
over several days and lethargy DISEASE . This morning patient developed
an acute worsening in dyspnea DISEASE and called EMS. EMS found patient
tachypnic at saturating 90% on 5L. Patient was noted to be
tripoding. She was given a nebulizer and brought to the ER.
.
According the patient's husband she was experiencing symptoms
consistent with prior COPD flares DISEASE . Apparently patient was
without cough chest pain fevers chills orthopnea DISEASE PND
dysuria diarrhea confusion DISEASE and neck pain DISEASE . Her husband is a
physician and gave her a dose of levaquin this morning.
.
In the ED patient was saturating 96% on NRB DISEASE . CXR did not reveal
any consolidation. Per report EKG was unremarkable. Laboratory
evaluation revealed a leukocytosis DISEASE if 14 and lactate of 2.2.
Patient received combivent nebs solumedrol 125 mg IV x1
aspirin 325 mg po x1. Mg sulfate 2 g IV x1 azithromycin 500 mg
IVx1 levofloxacin 750 mg IVx1 and Cefrtiaxone 1g IVx1. Patient
became tachpnic so was trialed on non-invasive ventilation but
became hypotensive DISEASE to systolics of 80 so noninvasive was
removed and patient did well on NRB DISEASE and nebulizers for about 2
hours. At that time patient became agitated hypoxic to 87% and
tachypnic to the 40s so patient was intubated. Post intubation
ABG was 7.3/60/88/31. Propafol was switched to
fentanyl/midazolam for hypotension DISEASE to the 80s. Received 2L of
NS. On transfer patient VS were 102 87/33 100% on 60% 450 x
18 PEEP 5. Patient has peripheral access x2.
.
In the ICU patient appeared comfortable.

Review of sytems:
limited due to patient sedation


Past Medical History:
# COPD DISEASE flare FEV1 40% in [**2120**] on 5L oxygen s/p intubation
[**6-6**] s/p distal tracheal to Left Main Stem stents placed
[**2118-6-9**]. Stents d/c'd [**2119-4-19**]. Tracheobronchoplasty performed [**6-6**] [**2119**]
# CAD w/ atypical angina DISEASE (cath [**2119**] - LAD 30% RCA 30% EF 63%)
# Dyslipidemia DISEASE
# Hypothyroidism DISEASE
# Hypertension DISEASE
# Hiatal hernia DISEASE
# lacunar CVA DISEASE
# s/p ped struck -Admission Date: [**2165-9-23**] Discharge Date: [**2165-9-28**]

Date of Birth: [**2114-1-13**] Sex: F

Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 51-year-old
African-American female with an extensive history of alcohol
abuse class B child cirrhosis DISEASE abstinent from alcohol since
[**2165-3-26**]. She saw her primary care physician on [**9-20**]
with complaints of a 5-day history of general malaise abdominal DISEASE
pain DISEASE and found to have white count of 26. Not notified until
three days thereafter when she was told to go to the Emergency
Room.

She presented to the Emergency Department with abdominal
pain hypotensive DISEASE to 60/30 baseline systolic pressure of 90
not responsive to intravenous fluids so started on dopamine
and sent to the unit.
On presentation her white count was 42 total bilirubin
was 7.2. Urinalysis positive for pan-sensitive Escherichia
coli. A subsequent abdomen ultrasound showed no ascites DISEASE . A
right upper quadrant ultrasound showed gallbladder inflammation DISEASE
consistent with cholecystitis DISEASE . Started on ceftriaxone
vancomycin and Flagyl. She had an endoscopic retrograde
cholangiopancreatography on the [**Hospital Ward Name **] with a common bile
duct stent transient elevation of amylase and lipase status post
stent. They were falling at the time of transfer. She was
weaned off pressors. Followed by Gastroenterology and General
Surgery.

On the evening of transfer to the Medicine Service she was
tolerating solids without nausea DISEASE and vomiting DISEASE . No nausea DISEASE or
vomiting DISEASE since admission. Guaiac-positive but hematocrit was
stable. Review of systems was negative. A history of
esophageal varices DISEASE . A 3-grade II one grade 3 on
esophagogastroduodenoscopy in [**2165-6-26**]. History of upper
gastrointestinal bleed DISEASE hemodynamically stable off pressors to
floor without problem.

PAST MEDICAL HISTORY:
1. Alcoholic hepatitis cirrhosisAdmission Date: [**2114-7-12**] Discharge Date: [**2114-7-29**]

Date of Birth: [**2040-9-4**] Sex: F

Service: CME


HISTORY OF PRESENT ILLNESS: The patient was originally
admitted to the Vascular Surgery Service and was then
transferred three to four days later to the C-MED Service.

This is a 73-year old female with coronary artery disease DISEASE
(status post coronary artery bypass grafting and multiple
cardiac catheterizations and percutaneous interventions at
outside hospitals) peripheral vascular disease DISEASE chronic
renal insufficiency DISEASE and insulin-dependent diabetes mellitus DISEASE
who was transferred to [**Hospital1 69**]
from an outside hospital to the Vascular Surgery Service with
a right lower extremity gangrenous ulceration. The reason
for transfer was for possible vascular intervention.

On arrival to the Vascular Surgery Service the patient's INR
was elevated as she had been on Coumadin for atrial
fibrillation DISEASE . She was given two units of fresh frozen plasma
to reverse her coagulopathy DISEASE and developed jaw pain DISEASE (her
anginal DISEASE equivalent) and went into acute cardiogenic DISEASE pulmonary
edema DISEASE . The patient was nearly intubated but improved with a
nitroglycerin drip and Natrecor.

She was then transferred to the C-MED Service for further
diuresis and because her exercise tolerance test sestamibi
obtained following her acute cardiogenic pulmonary edema DISEASE
showed reversible anterior defects DISEASE as well as partially
reversible lateral wall defects DISEASE . Her creatine kinase and
troponin were flat at the time of the acute cardiogenic DISEASE
pulmonary edema DISEASE . The patient did report some baseline
shortness of breath DISEASE but felt that it was worse at the time
of transfer to C-MED Service. However at baseline the
patient can only walk 15 feet with a walker and is limited by
anginal pain DISEASE or shortness of breath DISEASE . The patient did report
paroxysmal nocturnal dyspnea orthopnea DISEASE and lower extremity
edema DISEASE in the past - but not currently. The patient uses 2
liters of oxygen at home.

PAST MEDICAL HISTORY: Diabetes mellitus DISEASE .

Coronary artery diseaseAdmission DISEASE Date: [**2198-7-16**] Discharge Date: [**2198-7-28**]

Date of Birth: [**2153-5-26**] Sex: F

Service: SURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Leg pain erythema DISEASE and swelling DISEASE secondary to infection DISEASE of left
femoral-poplital bypass

Major Surgical or Invasive Procedure:
1. Incision and drainage and pulse irrigation of left groin and
left above-knee popliteal site incisions with xxploration of
bypass graft ([**2198-7-16**])
2. Excision of entire left common femoral artery-to-above-knee
popliteal artery bypass graftAdmission Date: [**2199-3-18**] Discharge Date: [**2199-3-22**]

Date of Birth: [**2153-5-26**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Latex / doxycycline

Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Chest pain DISEASE and nausea DISEASE for 5 days

Major Surgical or Invasive Procedure:
Cardiac Catherization [**2199-3-20**]

History of Present Illness:
Patient is a 45 yo F with PVD DM HL HTN DISEASE and OSA DISEASE . no known
CAD no history cath who presents with chest pain DISEASE and pressure
for 5 days. Patient was last in her usual state of health 5 days
prior to admission when she began to feel an intense chest
pressure and heaviness in the left chest radiating up to the jaw
while walking to her car. At this time she also felt intense
nausea DISEASE . The pain DISEASE and nausea DISEASE abated on its own but recurred more
intensely that night accompanied with vomiting DISEASE . At home she
took one of her boyfriend's nitroglycerin which brought about
partial relief of pain DISEASE . She continued over the weekend to have
pain nausea and vomiting DISEASE recurring which was relieved with her
boyfriend's nitroglycerin. In total she reports taking 7 nitros
for these episodes over the weekend. She had progressive fatigue DISEASE
as the days progressed and on day of presentation took a
shower after which she felt extreme pronounced fatigue DISEASE which
prompted her to present to the hospital. She reports worsening
orthopnea DISEASE and DOE. Also while she was on full dose aspirin due
to PVD DISEASE has not taken it while being on coumadin.
.
In the ED VS 98.4 83 104/64 16 100% RA EKG was read as non
acute and CXR was normal. Troponin and ckmb were neg x2. Patient
underwent stress MIBI which showed new partially reversible
inferior wall mild perfusion defect.

Past Medical History:
PMH:
asthma DISEASE
diabetes DISEASE type 2
anxiety DISEASE
LLE DVT
PVD DISEASE
HLD
HTN DISEASE
OSA DISEASE
.
PSH DISEASE :
b/l angiograms
L knee surgery x2
appendectomy
tonsillectomy
L fem-AK [**Doctor Last Name **] [**2198-6-11**] graft removal
[**7-17**]
vein patch angioplasty of L CFA/[**Doctor Last Name **] [**7-19**]
washout and complex wound closure [**7-26**].

Social History:
Moving in with her boyfriend. She has one child. She is
unemployed. Had a recent house fire and is currently living in
her daughter's house.
Tobacco history: 2ppd for past 25 yrs former 1.5ppd newly quit
on varenicline
Former cocaine use. (denies use for many years)
Drinks 5-6 drinks on weekends.
Hx of domestic violence.

Family History:
Mother had an abdominal aortic aneurysm DISEASE status post repair MI
in her mid 50s carotid stenosis cervical cancer DISEASE coronary
artery disease DISEASE other [**Month/Year (2) 1106**] lesions which were stented. She
died due to complications of a procedure. The patient's father
died young. The patient has one cousin with cervical cancer DISEASE . Her
maternal grandmother had an MI in her 60s. Maternal grandfather
with MI hypertension DISEASE and hypercholesteremia DISEASE .

Physical Exam:
PHYSICAL EXAM DISEASE ON ADMISSION:
VS: T98.3 BP125/71 HR69 RR18 O2sat 99%RA
GENERAL: WDWN in NAD. Oriented x3. Mood affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva were
pink no pallor or cyanosis DISEASE of the oral mucosa. No xanthalesma.

NECK: Supple with no JVD
CARDIAC: RRR normal S1 S2. No m/r/g. No thrills lifts. No S3
or S4.
LUNGS: No chest wall deformities scoliosis DISEASE or kyphosis DISEASE . Resp
were unlabored no accessory muscle use. CTAB no crackles
wheezes or rhonchi DISEASE .
ABDOMEN: Soft NTND. No HSM or tenderness DISEASE . Abd aorta not
enlarged by palpation. No abdominial bruits DISEASE .
EXTREMITIES: No c/c/e. No femoral bruits DISEASE .
SKIN: No stasis dermatitis ulcers DISEASE scars or xanthomas DISEASE no
arterial ulcers DISEASE
PULSES:
Right: radial 2Admission Date: [**2148-1-2**] Discharge Date: [**2148-1-6**]

Date of Birth: [**2085-9-6**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Lisinopril / Bupropion / Rosiglitazone Derivatives

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mrs. [**Known firstname 2894**] [**Known lastname 2895**] is a very nice 62 year-old woman with
significant past medical history of diabtes mellitus DISEASE type 2
hypertension hyperlipidemia DISEASE CAD s/p CABG who comes with three
weeks of shortness of breath and dyspnea DISEASE on excertion. Patient
states that she is not very active at home given baseline
shortness of breath DISEASE which is thought to be secondarely to her
heart disease DISEASE and COPD/Asthma but she is able to do 1 flight of
stairs with difficulty. However during the last 3 weeks she has
noted progressive SOB with less activity such as 10 steps. She
denies any nausea vomit cough chest pain palpitations DISEASE
wheezing DISEASE associated with the SOB. She still uses either 1 or no
pillows at night and can lie flat without difficulty. She
weights herself daily and has been with diet to try to lose
wieght. There have been no sick contacts and she denies any
fever chills rigors cough rhinorrhea arthralgias DISEASE muscle
pains diarrhea dysuria DISEASE urinary frequency. She went to see her
endocrinologist that follows her for her diabetes mellitus DISEASE and
was asked to come to our emergency room. Her VS at that time
were: BP 167/71 mmHg P 72 BPM SpO2 O2 93% oN RA DISEASE .
.
Per patient's report she had a stress test done in [**Month (only) **] last
year but could not walk for more than a couple of minutes.
There was no imaging done. She had not had a cardiac cath since
her CABG.
.
In the ER her initial VS were BP 163/61 mmHg P63 BPM RR 17
94% on RA DISEASE T 98.4 F. She had an ECG that showed occasional PVCs
with LVH DISEASE by Sokolow-[**Doctor Last Name **] cirteria with TWI in I II avL and
V5-V6 as well as Admission Date: [**2196-10-4**] Discharge Date: [**2196-10-9**]

Date of Birth: [**2129-4-3**] Sex: F

Service: [**Hospital Unit Name 196**]

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
MICU admission
Cardiac catheterization
Dialysis


History of Present Illness:
67yo female with CAD DMII ESRD who was initially admitted for
SOB on [**2196-10-4**]. Pt complained of increased SOB after dialysis
and was transferred to the MICU for closer monitoring of
respiratory status. CXR was consistent with CHF DISEASE and ECG showed
signs of mild ST depression DISEASE in I aVL and poor R wave
progression. Pt ruled in for NSTEMI with CK peak of 207 and
trop peak of 2.22 while in the MICU. Pt denied CP
palpitations DISEASE SOB.

Past Medical History:
DM II
ESRD DISEASE - on HD T Th S
CAD s/p NSTEMI [**10-8**] s/p LAD stent LCx stent at [**Hospital1 2025**] on [**10-5**]
uremic pericarditis DISEASE
tamponade DISEASE s/sp pericardiocentesis DISEASE 2'[**93**]
thyroid nodule
tachyarrythmia DISEASE
R arm AVG s/p thrombectomy

Social History:
Primarily Italian speaking women who lives by herself. Daughter
comes to visit 3-7x/week and patient also has son who is
involved and may take her in. Remote smotking history.

Family History:
Non-contributory.

Physical Exam:
PE:
VS: T: 97.9 BP: 147/53 HR: 65 RR: 20 SaO2: 98% on 4L
Gen: pleasant elderly women in NAD
HEENT: Pupil unequal dysconjugate gaze with R eye. mmm
Neck: supple no LAD JVP approximately 7cm
CV: RRR III/VI SEM at apex
Chest: crackles half way up chest/back bilaterally
Abd: soft NT ND BSAdmission Date: [**2144-9-4**] Discharge Date: [**2144-9-7**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
Cardiac Catherization


History of Present Illness:
79 yo male w/ past medical history significant for myasthenia DISEASE
[**Last Name (un) 2902**] complains of [**9-22**] pressure like substernal chest pain DISEASE
starting yesterday while lying in bed lasting 2 hours
unrelieved by tylenol or aspirin. Associated with diaphoresis DISEASE .
No shortness of breath DISEASE . Resolved on its own. Pt had recurrence
of pain DISEASE this morning upon awakening went to PMD's office and
was noted to have 1-[**Street Address(2) 1766**] elevations in V2-V3 was given
aspirin and sent to the ED. On arrival at ED he had [**8-22**] chest
pain DISEASE with 0.[**Street Address(2) 1755**] elevation in V2 1 mm elevation in V3 0.5
mmm elevation in V4 with TWI in V1-V4. He was taken to the cath
lab and found to have a 90% LAD occlusion DISEASE that was stented and
a non intervenable diffusely diseased RCA. He was also noted to
have normal right sided heart pressures with an oxygen step up
in the right atrium.

He denied doe pnd orthopnea dyspnea edema palpitations DISEASE
syncope DISEASE or presyncope DISEASE .

Past Medical History:
myasthenia DISEASE [**Last Name (un) 2902**] dx [**2138**]
post herpetic neuralgia DISEASE left leg
prostate cancer DISEASE s/p xrt [**2136**] and resection (TURP) [**2133**]
h/o thrombocytopenia DISEASE resolved
no history of cad diabetes hypercholesterolemia DISEASE or
hypertension DISEASE

Social History:
former chemical engineer married with four children no
smoking occ alcohol.

Family History:
mother: DM

Physical Exam:
Temp afebrile BP 163/82 Pulse 54 Resp 12 O2 sat 99%RA
Gen - Alert no acute distress
HEENT - NCAT PERRL extraocular motions intact anicteric
mucous membranes moist hard of hearing L ear.
Neck - 2Admission Date: [**2134-12-12**] Discharge Date: [**2135-1-3**]

Date of Birth: [**2069-2-21**] Sex: M

Service: Cardiothoracic Service

HISTORY OF PRESENT ILLNESS: The patient is a 68 year old man
with a two week history of increasing shortness of breath DISEASE
admitted to the [**Hospital6 2910**] on [**12-6**]
where he ruled in for an myocardial infarction DISEASE . The patient
with known cardiomyopathy DISEASE of unclear etiology with known
coronary artery disease DISEASE by MIBI echocardiogram scheduled for
an elective catheterization but had increasing shortness of breath and dyspnea DISEASE on exertion DISEASE therefore admitted prior to
his cardiac catheterization and ruled in for non-Q wave
myocardial infarction DISEASE . His catheterization at [**Hospital6 2911**] showed 50% left main left main 80% left anterior
descending 70% right coronary artery with an ejection
fraction of 20%. The patient was in congestive heart failure DISEASE
at the time. He was started on Dobutamine with relief of
symptoms and was transferred to [**Hospital6 2018**] for coronary artery bypass grafting. Catheterization
done at that time also showed an aortic valvular area of 0.8
cm squared. He has a history of syncopal DISEASE episodes.
Therefore his catheterization was to be repeated after
arrival at [**Hospital6 256**].

PAST MEDICAL HISTORY: Significant for diabetes mellitus DISEASE
hypertension cardiomyopathy DISEASE elevated lipids.

PAST SURGICAL HISTORY: Significant for penile DISEASE prosthesis and
L4-5 fusion.

MEDICATIONS ON ADMISSION: Insulin 70/30 60 units b.i.d.Admission Date: [**2197-4-4**] Discharge Date: [**2197-4-8**]

Date of Birth: [**2157-1-25**] Sex: F

Service:

ADMISSION DIAGNOSES:
1. Chronic pelvic pain DISEASE .
2. Enlarged multifibroid uterus.
3. Endometriosis.

DISCHARGE DIAGNOSES:
1. Chronic pelvic pain DISEASE .
2. Enlarged multifibroid uterus.
3. Endometriosis.

INDICATIONS FOR ADMISSION: The patient had a longstanding
history of endometriosis DISEASE with priory surgery dating back to
[**2186**]. She had gone on to develop an enlarged 12-week to
15-week size multifibroid uterus along with additional cystic
change of the ovary. She was not planning to have children
and when consulted on the various options agreed to surgery
with a goal of removing the uterus and adnexa in an effort to
manage her chronic pelvic pain DISEASE and bleeding DISEASE .

BRIEF SUMMARY OF HOSPITAL COURSE: On the day of admission
she was taken to the operating room and underwent extensive
surgery
via laparotomy. The procedure was complicated by a left
ureteral transection which was repaired under the auspices of
the Urology Service ( a separate Operative Note was dictated
for that. Additionally due to the intense fibrotic scarring
secondary to her endometriosis DISEASE consultation was requested
from Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 2920**] [**Doctor Last Name 1022**] who graciously assisted in completing
dissection of the uterus and adnexa ultimately resulting in
a total abdominal hysterectomy and bilateral
salpingo-oophorectomy which confirmed endometriotic changes.
There was a great deal of dissection involved in separating
the posterior uterine surface from the bowel but no entry
into the bowel occurred.

Her intraoperative course was punctuated by receipt of two
units of transfused packed red blood cells. Due to
continuing anemia DISEASE she received an additional three units on
[**2197-4-7**]. Her lowest hematocrit appeared to be 24 and at
discharge had risen to 27.9.

Her postoperative course basically was smooth. She did
receive intravenous antibiotics. A urinary stent had been
placed in the left ureter which was to be removed
approximately 10 days postoperatively in the urologist's
office. She remained stable throughout the course and began
to pass gas within two to three days and had resumption of
bowel function. Pain control was managed with narcotic
analgesics.

She was discharged on her sixth postoperative day in stable
condition. She was afebrile with a hematocrit of 27.9. She
was to continue replacement iron and was to be seen the
following week for removal of the urinary catheter. She was
subsequently seen also in my office for scheduled
postoperative appointments and was making a uncomplicated
recovery at that point.

FINAL DISCHARGE DIAGNOSES:
1. Chronic pelvic pain DISEASE .
2. Multifibroid uterus.
3. Endometriosis (severe stage 4).

DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient will continue
to be followed at the [**University/College **] office of [**Hospital1 2921**].





[**First Name11 (Name Pattern1) 2922**] [**Last Name (NamePattern4) 2923**] M.D. [**MD Number(1) 2924**]

Dictated By:[**Last Name (NamePattern4) 2925**]

MEDQUIST36

D: [**2197-8-29**] 22:03
T: [**2197-9-2**] 04:46
JOB#: [**Job Number 2926**]
Admission Date: [**2148-4-2**] Discharge Date: [**2148-4-16**]

Date of Birth: [**2069-6-14**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
Phenobarbital

Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
transferred for seizure DISEASE management


Major Surgical or Invasive Procedure:
Intubation
Long Term EEG monitoring


History of Present Illness:
78yo RH M h/o brain tumor DISEASE s/p R frontal resection in [**2132**] CAD
hyperlipidemia prostate cancer DISEASE s/p XRT and seizure disorder DISEASE who
is transferred for increasing seizures DISEASE .
.
He initially presented to OSH on [**3-29**] with Unit No: [**Numeric Identifier 2929**]
Admission Date: [**2148-2-5**]
Discharge Date: [**2148-2-10**]
Sex: F
Service: NSU


HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
woman status post a fall with a right-sided subdural
hematoma DISEASE . The patient had an elevated INR secondary to
Coumadin for atrial fibrillation DISEASE . She was taken emergently
to the OR for a craniotomy for evacuation of this right-sided
subdural hematoma DISEASE . A CT scan showed a large right-sided
subdural hematoma DISEASE measuring 1.5 cm in size with midline shift
and subfalcine herniation. Laboratories on admission
revealed a white count of 7.5 crit 31.1 platelets 375000.
Sodium 134 potassium 6.4 chloride 100 C02 24 BUN 11
creatinine 0.8 glucose 93. INR on admission was 1.4.

PHYSICAL EXAMINATION: The patient on physical examination
was intubated and sedated. HEENT: The patient's right pupil
was dilated and sluggishly reactive. Respiratory rate
revealed coarse breath sounds. Cardiovascular revealed S1
and S2 A paced. The abdomen was soft positive bowel
sounds. Extremities: She has some left upper extremity
swelling DISEASE .

HOSPITAL COURSE: She is status post a right subdural
hematoma DISEASE evacuation without intraoperative complications.
She was monitored in the ICU. On postoperative check she was
alert and attentive opening her eyes following commands
times four although still intubated. She had a
postoperative CT which was stable. Her blood pressure was
kept less than 160 and she was weaned to extubate. The
patient had bradycardia DISEASE during surgery so EP came and
interrogated her pacemaker. She was in the DDD mode and her
pacer was functioning appropriately.

On [**2148-2-7**] the patient had a repeat head CT which
was stable. The patient was successfully extubated
following commands times four. PT and OT were ordered to
evaluate the patient and the patient remained neurologically
stable. She was transferred to the regular floor on
[**2148-2-7**]. She was in stable condition. She was evaluated by
physical therapy and occupational therapy and found to
require a short rehabilitation stay prior to discharge home.

MEDICATIONS:
1. Famotidine 20 mg p.o. twice daily.
2. Dilantin 100 mg p.o. three times daily.
3. Heparin 5000 units subcutaneously twice daily.
4. Lasix 20 mg p.o. daily.
5. Sotalol 80 mg p.o. twice daily.
6. Valsartan 40 mg p.o. daily.
7. Colace 100 mg p.o. twice daily.
8. Diltiazem 90 mg p.o. four times daily.
9. Isosorbide 20 mg p.o. twice daily.
10. Albuterol inhaler one to two puffs every six hours
as needed.
11. Ipratropium bromide one nebulizer inhaler every six
hours as needed for wheezing DISEASE .

The patient remained neurologically stable. She was
evaluated by PT and OT and felt to require rehabilitation.
The staples can be removed on postoperative day number ten.
The patient had the surgery on [**2148-2-5**].

CONDITION ON DISCHARGE: Stable.

FOLLOW UP: The patient will follow-up with Dr. [**Last Name (STitle) 739**]
in two weeks with a repeat head CT.

ADDENDUM: On repeat head CT the patient also had a left-
sided chronic subdural hematoma DISEASE which did enlarge once the
right-sided subdural hematoma DISEASE was evacuated and that will
require further evaluation with repeat head CT in two weeks
with Dr. [**Last Name (STitle) 739**].



[**Name6 (MD) **] [**Name8 (MD) 739**] MD [**MD Number(2) 2930**]

Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2148-2-9**] 16:16:53
T: [**2148-2-9**] 16:41:55
Job#: [**Job Number 2931**]



Admission Date: [**2170-9-1**] Discharge Date: [**2170-9-5**]

Date of Birth: [**2114-1-13**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Levofloxacin / Codeine / Bactrim Ds

Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
none

History of Present Illness:
56F with EtOH cirrhosis DISEASE initially found unresponsive in AM 3d
ago. FSBGs 200s no e/o sz and initially intubated on arrival
to the ED for airway protection. CT head was negative LP
deferred [**12-28**] coagulopathy DISEASE . Pt. with h/o of poor compliance with
encephalopathy DISEASE meds and mutliple admissions in past for AMS
though pt. reports compliance with meds and [**12-29**] BMS/day. Pt. was
extubated yesterday without complication and has had no e/o
withdrawal on this admission (per pt. last ETOH in [**Month (only) **]). Pt.
with dirty U/A on admit and sputum cx. growing GAdmission Date: [**2184-1-30**] Discharge Date: [**2184-2-5**]

Date of Birth: [**2120-1-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
central line placement

History of Present Illness:
64 year old male with a past medical history significant for
atrial fibrillation DISEASE and bipolar disorder DISEASE presented with fever DISEASE
rigors DISEASE and sore DISEASE throat. Mr. [**Known lastname 2933**] states that he developed
sore throat and cough DISEASE productive of grayish-yellow sputum 2 days
ago. He took some aspirin and cepachol without significant
relief. On the day of admission his wife noted that he was
confused warm and breathing shallowly. In the ED rectal temp Admission Date: [**2185-7-6**] Discharge Date: [**2185-7-8**]

Date of Birth: [**2120-1-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Pneumovax 23

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
weakness achyness DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
. Boiseau is a pleasant 65 yo man with paroxysmal atrial
fibrillation bipolar disorder DISEASE and h/o EtOH abuse who presented
to the ED today with complaints of R arm pain DISEASE achiness and
Admission Date: [**2186-5-2**] Discharge Date: [**2186-5-10**]

Date of Birth: [**2120-1-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Pneumovax 23

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Diarrhea Weakness Pneumonia DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
66M hx pAF C diff recent at St E for PNA home from rehab x
few days wife noted sats down (95-96 on 2 L NC up to 3-4 L this
AM) more letharagic poor POs today 102F recent tx for C
diff now increased volume diarrhea DISEASE .
.
Per records from [**Hospital 2940**] admission [**2186-3-29**] treated for C diff
with Flagyl in addition to Vanc/Zosyn for PNA. Blood cx
positive for VRE DISEASE started on Linezolid. BAL grew Enterobacter
cloacae (treated with Zosyn). Pt also had pancytopenia DISEASE had
marrow bx penia attributed to infection DISEASE vs fecainide which was
discontinued.
.
In [**Name (NI) **] pt noted to have a cough DISEASE crackles R base BP 160s down
to 80s abd soft bilat LE edema DISEASE . Vitals: 103.8R HR 90s
160/90 sat 94 on 5L. BP mid 80s given 3 L NS. Tylenol brought
temp down to 101.8. Pt noted to be confused at times. Lactate
2.4. CXR with RLL infilrate. UA neg. Antibiotics given:
CTX/Vanc/Levaquin/Flagyl. FULL Code.
.
On arrival to the ICU pt was in NAD speaking in full
sentences A&Ox3.
.
Review of sytems:
(Admission Date: [**2186-6-14**] Discharge Date: [**2186-6-21**]

Date of Birth: [**2120-1-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Pneumovax 23

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Mental Status Changes/Hypoxia DISEASE

Major Surgical or Invasive Procedure:
Lumbar Puncture

History of Present Illness:
This is a 66 year old male with hepatitis C DISEASE history of alcohol
abuse bipolar affective disorder atrial fibrillation DISEASE and a
recent admission to [**Hospital1 18**] for pneumonia DISEASE who was transferred from
an outside hospital where he had presented with mental status
changes and dyspnea DISEASE . The patient was not able to give a full
account of the circumstances leading to his admission but per
his family he had increasing dyspnea DISEASE and confusion DISEASE starting
approximately five days prior to presentation. He may have had
chills DISEASE but no fevers DISEASE and he was noted to be extremely fatigued.
At the outside hospital he was febrile DISEASE bradycardic
hypotensive DISEASE non-verbal pale and not following commands
reliably. After initial lab results did not reveal a clear
source of his illness he was transferred to [**Hospital1 18**] for further
management.

In the [**Hospital1 18**] ED initial vitals were T 100 BP 89/40 HR 45 RR
16 94% on 2L. Over his ED course he became progressively more
hypoxic and eventually required 4.5L of O2 by nasal cannula to
maintain a sat of 92%. He was initially bradycardic with rates
in the 40's but this spontaneously improved to 70s-90s without
interventions. His SBP's improved to 90's-100's with 2L IVF.
His chest radiograph revealed a right middle lobe infiltrate
which he had recently been treated for at [**Hospital1 18**] (admission until
[**2186-5-10**]). He received vancomycin and levofloxacin for a
possible pulmonary infection DISEASE as well as IV metronidazole as the
patient had diarrhea DISEASE and had C diff in [**Month (only) 958**]. He was
transferred to the ICU for further management.


Past Medical History:
- Atrial Fibrillation DISEASE
- History of clostridium difficile DISEASE
- Bipolar Affective DISEASE Disorder
- History of hepatitis DISEASE C
- History of rheumatic heart disease DISEASE
- History of right middle cerebral artery aneurysm clipped in
[**2167**] at [**Hospital6 1708**]
- History of pernicious anemia DISEASE
- Gastroesophageal reflux disease DISEASE

Social History:
He lives with his wife. [**Name (NI) **] has a history of alcohol abuse but
this was greater than twenty years ago. He stopped smoking
after his previous hospitalization (about one month prior to
presentation) but previously had a 40 pack year history. He had
been discharged from his last hospitalization with oxygen but
had not been using this prior to admission.

Family History:
His father had lung cancer DISEASE and his mother had congestive heart failure DISEASE .

Physical Exam:
On Presentation to ICU
VS - T 96.2Admission DISEASE Date: [**2186-6-23**] Discharge Date: [**2186-7-6**]

Date of Birth: [**2120-1-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Pneumovax 23

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
pneumonia hypoxia hypotension DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The pt is a 66-yo man with paroxysmal atrial fibrillation DISEASE
hepatitis C DISEASE h/o C.diff colitis DISEASE and a recent pneumonia DISEASE
discharged [**2186-6-21**] on Vanc / Zosyn who was found by his family
to be more hypoxic and tired than usual so they brought him into
the ED. His wife found him to be more sick than usual at about
4pm today needing more supplemental O2 than prior (2L --Admission Date: [**2186-8-7**] Discharge Date: [**2186-8-26**]

Date of Birth: [**2120-1-2**] Sex: M

Service: SURGERY

Allergies DISEASE :
Pneumovax 23

Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
c diff colitis DISEASE

Major [**First Name3 (LF) 2947**] or Invasive Procedure:
none

History of Present Illness:
HPI: The patient is a 66-year-old male who is known to have C.
difficile colitis DISEASE and was admitted to the Gold surgery service
in
3/[**2186**]. He was referred to [**Hospital1 18**] for weakness rigidity DISEASE
lethargy DISEASE decreased level of interaction and anorexia DISEASE . About a
week ago he began having diarrhea DISEASE . He has been on metronidazole
500mg po BID for several weeks.

In the ED his initial vital signs were 97.3 129 146/93 18 99RA.
His heart rate stabilized to 80-90s after 2 liters of IVF. At
around 23:30 he became acutely hypotensive DISEASE to SBP of 80s-90s
maintaining his heart rate in the 90s. ICU bed was arranged for
close monitoring.


Past Medical History:
- Paroxysmal Atrial Fibrillation DISEASE
- History of C diff colitis DISEASE
- Bipolar Affective DISEASE Disorder
- History of resolved hepatitis B DISEASE
- History of rheumatic heart disease DISEASE
- History of right MCA aneurysm clipped in [**2167**] at [**Hospital1 112**]
- History of pernicious anemia DISEASE
- Gastroesophageal reflux disease DISEASE

Social History:
He lives with his wife. Questionable history of alcohol abuse
(did abuse alcohol Admission Date: [**2136-1-25**] Discharge Date: [**2136-2-3**]


Service: MEDICINE

Allergies DISEASE :
Nitroglycerin

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
palpitations chest pain abdominal pain DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
[**Age over 90 **]y/o Russian speaking F with CAD severe AS HTN DISEASE and atrial
fibrillation DISEASE presenting with chest pain DISEASE SOB palpatations and
abdominal pain DISEASE . She was in her USOH until the past week per the
daughter and this includes intermittant chest pain DISEASE and
palpatations. Over the past week however she has complained of
dull transient upper abdominal pain DISEASE especially with food and
more frequent episodes of chest pain DISEASE and palpatations. Her chest
pain DISEASE can occur either with exertion (walks at home with a cane
or walker) or at rest. She denies any recent fevers chills DISEASE
sick contacts N/V diarrhea weakness paresthesias DISEASE
visual/auditory changes dysuria rash DISEASE or mental status
changes. She has mild orthopnea DISEASE and DOE both of which are
baseline but has been mildly more SOB this week.
.
In the ED she was found to be in Afib DISEASE w/ RVR up to the 130s and
received 10mg IV diltiazem x 3 and given 30mg PO diltiazem. A
RUQ ultrasound revealed dilated biliary and pancreatic ducts DISEASE and
her pain DISEASE was controlled with IV morphine 0.5mg x 2. ERCP was
contact[**Name (NI) **] and plan to take the patient for an exam in the AM.
.
On the floor the patient remained tachycardic and she remained
tachypneic. The MICU was called to evaluate the patient for
possible admission given her high nursing needs. On evaluation
the patient Admission Date: [**2136-5-25**] Discharge Date: [**2136-5-26**]


Service: MEDICINE

Allergies DISEASE :
Nitroglycerin

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
cough/hypoxia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The patient is a [**Age over 90 **] year old woman with history of severe aortic
stenosis atrial fibrillation DISEASE chronic anemia DISEASE who presents from
her chest and abdominal pain DISEASE with worsening cough DISEASE for the past 2
days. The abdominal pain DISEASE and difficulty breathing worsened over
the last four hours prior to coming to the hospital.
.
In the ED her initial vital signs were 101.8(rectal) 140 113/90
43 97%4L. Peripheral IVs were placed and 2L of NS saline was
given in total. She received ceftriaxone/levofloxacin for CAP. A
bedside u/s was negative for free fluid. She also received 1
dose of lopressor (2.5mg) without effect. Her pain DISEASE improved but
blood pressure started to decrease 90 HR 105 Sat 100 on NRB
still tachypneic Admission Date: [**2183-7-23**] Discharge Date: [**2183-7-30**]

Date of Birth: [**2105-12-3**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Left non-small cell lung cancer DISEASE diagnosed in 6/[**2182**].


Major Surgical or Invasive Procedure:
[**2183-7-23**]: bronchoscopy and mediastonoscopy
[**2183-7-25**]: LUL segmentectomy LLL wedge resection


History of Present Illness:
Mr. [**Known lastname 2970**] is a 77-year-old gentleman referred by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1391**] to Dr. [**Last Name (STitle) **] for advice and options regarding a
carcinoma of the lung DISEASE detected during recent hospitalization for
coronary disease DISEASE and a large aortic aneurysm DISEASE in [**2183-5-8**]. A
lesion in the left lung was discovered in the upper lobe and a
needle biopsy confirmed non-small cell carcinoma DISEASE . He underwent
a PET scan which showed extreme hypermetabolism DISEASE with an SUV of
17 at the site of the lung primary lesion. There is sparse
uptake within the mediastinum not considered of pathologic
significance as well as active inflammation DISEASE around the
abdominal graft.

He presented to [**Hospital1 18**] on [**2183-7-23**] for an operation to address his
left non-small cell lung cancer DISEASE .


Past Medical History:
Significant for coronary disease DISEASE status
post an infarction DISEASE . He has aortic aneurysm DISEASE increased serum
cholesterol prostate cancer and carcinoma of the sigmoid DISEASE
colon.

PAST SURGICAL HISTORY: Sigmoid colectomy in [**2171**] radical
prostatectomy in [**2169**] and the tube graft repair of his
abdominal
aortic aneurysm DISEASE .


Social History:
He has substantial prior smoking history just recently quit.
He has no active alcohol issues.


Physical Exam:
VITAL SIGNS: Weight of 148 pounds. He is afebrile blood
pressure 140/83 pulse 74 and regular and room air saturation
is
95%.
LUNGS: His lung fields are surprisingly clear.
HEART: Regular rhythm and rate without murmur or gallop.
NECK: There were no carotid bruits DISEASE .
ABDOMEN: Soft and nontender with good healing ridge along the
wound.
EXTREMITIES: He has no peripheral edema DISEASE .


Brief Hospital Course:
The patient presented to [**Hospital1 18**] on the day of planned surgery.
He was noted to have significant bradycardia DISEASE prior to starting
the operation. He did undergo a flexible bronchoscopy and
mediastinoscopy that was complicated by substantial
intraoperative bleeding DISEASE . He was subsequently ruled out for a
cardiac event and remained
hemodynamically and neurologically stable on POD#1. On HD#3 the
decision was made to proceed with a segmental resection given
the T2 size of the lesion and his limited baseline lung
function. Please refer to both operative notes of [**2183-7-23**] and
[**2183-7-25**] for further details of the procedures. An epidural was
placed for postoperative pain DISEASE control on [**2183-7-25**]. Two left-sided
chest tubes were placed intraoperatively and a post-operative
chest radiograph showed a moderate left sided pneumothorax DISEASE .

On [**2183-7-25**] he was transfused 1 unit of packed RBCs for a
hemtocrit of 27.6. The Acute Pain DISEASE Service continued to follow
the patient for management of the epidural catheter. He was
admitted to the CSRU for a day after surgery and was transferred
to the floor on [**7-26**] after he was deemed to be stable. His chest
tubes were placed to water seal and a chest radiograph showed
very slight increase in left pneomothorax.

On [**7-27**] his anterior chest tube which was placed
intraoperatively was removed without incident and his second
tube was put to bulb suction. A chest radiograph that was done
after these changes were made showed no acute or concerning
changes in the left pneumothorax. His epidural catheter was
removed and he was given oral pain DISEASE medications.

On [**7-28**] the patient's foley catheter was discontinued but the
patient failed to void 12 hours after removal. He was
administered tamsulosin and his foley catheter was replaced. A
PA and lateral chest radiograph showed decreased left-sided
pneumothorax DISEASE and interstitial edema DISEASE since the prior examination
with small bilateral pleural effusions DISEASE .

On [**2183-7-29**] he underwent a video swallow study which revealed a
left vocal cord paralysis DISEASE . The speech consultant recommended the
following:
1. Diet of thin liquids and soft solids
2. Swallow w/chin tucked to chest for all consistencies
3. Pills whole in applesauce
4. ENT consult to evaluate vocal cord mobility to r/o Left
vocal cord paresis/paralysis

An otolaryngology consult was obtained for evaluation and
treatment for this condition the recommendation which were to
observe strict chin-tuck adherence and strict aspiration
precautions as the patient was thought to be at great aspiration
riskAdmission Date: [**2187-3-26**] Discharge Date: [**2187-4-5**]

Date of Birth: [**2105-12-3**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
LLQ Pain DISEASE and BRBPR

Major Surgical or Invasive Procedure:
none

History of Present Illness:
81 y/o M w/ h/o AAA s/p repair colon ca s/p sigmoidectomy
diverticulitis prostate cancer DISEASE and non-small cell lung cancer DISEASE
p/w 4 days of LLQ pain DISEASE . Patient states that for the past four
days he has had a band like abdominal pain DISEASE across his lower
abdomen. On day of admission his home health aide noted bright
red blood in his stools and so patient referred to the ED.
.
In the ED initial vs were: VS 97.8 106 129/83 18 100%. Patient
with BRB on DRE and mild LLQ pain DISEASE (intermittent). HR improved
with 1L NS. CT A/P done in ED showed no acute abdominal
pathology c/w patient's symptoms. Patient was observed and had
one further episode of BRBPR in the ED prior to ICU transfer.
Repeat Hgb went from 10.9 on arrival to 8.2 (baseline Hgb
[**11-19**]).
.
On arrival to the ICU patient comfortable with stable VS. On
further questioning denies any recent f/c/n/v/ns/diarrhea/
constipation/weight gain DISEASE or weight loss/chest pain/syncope or
other complaints. Denies melena DISEASE .
Review of systems:
(Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-11**]

Date of Birth: [**2124-11-5**] Sex: M

Service: [**Hospital Ward Name **] ICU

CHIEF COMPLAINT: Admission Date: [**2147-11-20**] Discharge Date: [**2147-11-24**]

Date of Birth: [**2077-6-20**] Sex: M

Service: ORTHOPAEDICS

Allergies DISEASE :
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 2988**]
Chief Complaint:
progressive bilateral leg weakness

Major Surgical or Invasive Procedure:
s/p L3-S1 lami/fusion with instrumentation [**2147-11-20**]


History of Present Illness:
70 y.o M p/w progressive lower back pains/leg weakness. Pt
having difficulty walking. Has transitioned from cane to walker
over past week. MRI noted for severe L3-L5 spinal stenosis DISEASE .

Past Medical History:
Hand tremors DISEASE
Chronic neck pain DISEASE
Diverticulosis s/p sigmoid DISEASE colectomy
Urinary incontenence

PSHx:
ORIF right leg
ORIF left forearm
Sigmoid colectomy
Cataract DISEASE


Social History:
married lives with wife - tobacco Admission Date: [**2136-2-24**] Discharge Date: [**2136-3-8**]

Date of Birth: [**2083-3-11**] Sex: M

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
1. Severe abdominal pain DISEASE

Major Surgical or Invasive Procedure:
[**2136-2-24**]: Sigmoid colon resection and end colostomy.


History of Present Illness:
The patient is a 52 year old male who complains of ABD PAIN and
unable to urinate. She was seen in the ED one week ago for left
lower quadrant pain DISEASE diagnosed with diverticulitis DISEASE and placed
on Cipro Flagyl. That left lower quadrant pain has been
gradually improving. However he urinated last night
normally and then has been unable to urinate since then and
developed lower abdominal pain DISEASE this morning. No nausea vomiting DISEASE
fevers DISEASE or chills DISEASE .


Past Medical History:
PMH: diverticulitis DISEASE
PSH DISEASE : exploratory laparoscopy exploratory laparotomy (stabbing)


Social History:
The patient is a smoker and drinks occasional alcohol.


Family History:
Non contributory

Physical Exam:
On Admission:
VS: T98.1 HR 90s BP 150/60 RR 18 Sats 100%RA
General:In moderate distress
HEENT-anicteric
CV-RRR
Pulm-CTA b/l
Abd-rigid rebound guarding diffuse abd tenderness DISEASE . Well
healed midline scar.
Ext-no edema DISEASE

On Discharge:
VS:
General: NAD
Head/Neck: NC/AT supple
Heart: RRR no m/r/g
Lungs: Left CTA right - diminished on base
Abd: Distended firm tenderness around incision sites. Midline
incision: distal and proximal part with staplesAdmission Date: [**2138-8-25**] Discharge Date: [**2138-10-3**]


Service: MEDICINE

Allergies DISEASE :
Sulfonamides / Macrodantin / Codeine / Norvasc / Hydralazine /
Heparin Agents

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
anemia DISEASE and acute renal failure DISEASE

Major Surgical or Invasive Procedure:
Renal biopsy [**9-1**]
Placement of pheresis catheter [**9-3**]
Plasma exchange [**9-3**] [**9-5**] [**9-8**]
Hemodialysis
Bronchoscopy [**2138-9-12**]
Central line placement [**2138-9-12**]

History of Present Illness:
[**Age over 90 **] year-old female with hypertension DISEASE admitted [**2138-8-25**] with acute
renal failure DISEASE secondary to hydralazine-induced
glomerulonephritis DISEASE (p-ANCA positive). Patient was initially
nonresponsive to steroids plasma exchange and was started on
hemodialysis on [**2138-9-9**]. She received her second HD treatment on
[**2138-9-11**]. During both treatments L IVF was removed. Both renal
and rheumatology have followed patient to date. Cyclophosphamide
was considered but not started given concern for toxicity DISEASE due
to age.
.
Overnight patient developed oxygen requirement initially
hypoxic to 90% on room air at rest 85% with ambulation. Oxygen
delivery was increased progressively from 3L to 6L nasal
cannula. She appeared volume overloaded on exam and CXR. She was
given Lasix 40mg IV x2 with minimal urine output. Nebulizers
were tried with minimal relief. Renal was called re: urgent
dialysis which was not possible. Additionally given rapid
progression of hypoxia DISEASE renal suspected etiology other than
volume overload DISEASE alone. Of note patient also with hemoptysis DISEASE
this morning on multiple occasions - largest approximately 1
teaspoon bright red blood. Given progressive hypoxia DISEASE and
increased work of breathing patient is transferred to [**Hospital Unit Name 153**] for
further management.
.
Hospital course also complicated by lower GI bleed anemia DISEASE
coagulopathy UTI DISEASE . On [**2138-9-10**] patient developed LGIB DISEASE in context
of constipation DISEASE and straining for bowel movement. GI was
consulted. Based on recent colonoscopy transient diverticular
bleed DISEASE was suspected. Ischemic colitis DISEASE was also considered given
underlying vasculitis DISEASE . Patient also with chronic anemia DISEASE . She has
required 2 pRBC transfusions during this hospital course.
Patient also with uncomplicated UTI DISEASE treated with ciprofloxacin
PO x3 days on admission.
.
On arrival to [**Hospital Unit Name 153**] was with O2 saturation 100% on 100% O2 shovel mask. She complained of shortness of breath fatigue DISEASE . She
was urgently intubated given respiratory distress DISEASE .


Past Medical History:
Hepatitis B DISEASE secondary to transfusion ([**2078**])
Hypercholestremia
Hypertension DISEASE
Carotid stenosis DISEASE s/p endartarectomy
Arthritis DISEASE s/p right THR ([**2130**])
Gastritis DISEASE
Prolapsed bladder s/p bladder DISEASE suspension
Breast cyst DISEASE


Social History:
Lives in apartment above daughter's home. Well-supported by
family. Active prior to admission - capable in all ADLs. Per
daughter no tobacco alcohol or illicit drug use. Formerly
worked at [**Company 3004**].

Family History:
unknown

Physical Exam:
On admission [**2138-8-26**]:
Pt is at baseline per daughter who is with pt
Pt is awake and responds appropriately. Able to tell me it is
[**2138**] but unable to correctly tell me month or date or identify
name of president.
97.8 197/77 78 14 99%RA
CV-RRR
lungs - CTA bilat
abd - soft nt nD no guarding
ext - no c/c/e
.
On admission to [**Hospital Unit Name 153**] (prior to intubation) [**2138-9-12**]:
96.8 95 169/112 20 91% shovel mask 100%
General: Labored respirations with use of accessory muscles
HEENT: Sclera anicteric dry blood DISEASE at mucous membranes and in
mouth no site of active bleeding DISEASE
Neck: Supple JVP difficult to assess given accessory muscle
use
Lungs: Rhoncherous throughout with crackles to midlung fields
bilaterallyAdmission Date: [**2148-4-22**] Discharge Date: [**2148-4-28**]

Date of Birth: [**2090-4-5**] Sex: M

Service: ORTHOPAEDICS

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3006**]
Chief Complaint:
left thumb amputation

Major Surgical or Invasive Procedure:
[**2148-4-22**]: Dr. [**Last Name (STitle) **] - left thumb complete reimplantation at
the level of the proximal MP joint.


History of Present Illness:
58 year old right hand dominant man who accidently amputated his
left thumb at the level of the distal metacarpal with a circular
saw when doing floor work at Admission Date: [**2135-2-8**] Discharge Date: [**2135-2-14**]

Date of Birth: [**2052-1-30**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Bactrim

Attending:[**Doctor First Name 2080**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
thoracentesis

History of Present Illness:
Reason for MICU Admission: hypoxia DISEASE respiratory distress
.
Primary Care Physician: [**Name10 (NameIs) 585**][**Name11 (NameIs) 586**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 589**]
.
CC: cough shortness DISEASE of breath
.
HPI: 83yo female Russian with history of CLL DISEASE presenting with
respiratory distress DISEASE .
.
Per patient she reports 6 days of productive cough DISEASE and
progressive dyspnea DISEASE . She reports associated fevers DISEASE up to 100.2
and sore throat. Two days prior to admission prescribed bactrim
by her son who is a physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 3010**] worsened and she
presented to her PCP [**Name Initial (PRE) 3011**]. There vital signs notable for O2 sat
89% RA DISEASE improved to 92% on 2L NC. CXR with right increased
effusion and possible left sided infiltrate. She was referred to
ED for further eval.
.
In the ED initial VS: 99.3 81 118/46 20 96% NRB DISEASE . Labs notable
for WBC of 33.2 61% lymphocytesAdmission Date: [**2196-8-16**] Discharge Date: [**2196-8-18**]

Date of Birth: [**2160-7-23**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Bactrim / Vioxx / Penicillins / Cellcept / Ceftriaxone /
Ferrlecit

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
peritoneal dialysis

History of Present Illness:
Ms. [**Known lastname **] is a 36 year old female with a history of SLE lupus DISEASE
nephritis ESRD DISEASE on PD DISEASE who presented to the ER with two days of
chest pain DISEASE and worsening shortness of breath DISEASE . At home she had
been having pain DISEASE . She had been having pain DISEASE during her PD DISEASE
sessions at home and was having difficulty tolerating the PD DISEASE
sessions so she stopped doing her home PD DISEASE sessions Sunday
evening. Over the next few days she started having more
shortness of breath DISEASE was experiencing chest heaviness orthopnea DISEASE
and PND. Her shortness of breath DISEASE worsened over and she
presented to the ER today for further evaluation. She denies any
cough nasal congestion DISEASE fever/chills night sweats DISEASE n/v/d. Does
have her baseline abdominal pain DISEASE and has felt worsening
Admission Date: [**2198-4-22**] Discharge Date: [**2198-5-4**]

Date of Birth: [**2160-7-23**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Bactrim / Vioxx / Penicillins / CellCept / Ceftriaxone /
Ferrlecit / Sulfa (Sulfonamide Antibiotics)

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
HEMOPTYSIS

Major Surgical or Invasive Procedure:
LEFT BRONCHIAL ARTERY EMBOLIZATION UNDER FLUOROSCOPY
RIGHT INTERNAL JUGULAR LINE PLACEMENT REPOSITIONING AND
REMOVAL
IVC FILTER PLACEMENT
INTUBATION AND MECHANICAL VENTILATION

History of Present Illness:
37F with history of lupus lupus nephritis DISEASE with ESRD DISEASE on
peritoneal dialysis on transplant list hx of PE/Antiphopholipid
antibody on coumadin mitral regurg presents with 4-6 month
history of cough DISEASE worse in the morning one week of trace blood
now producing bright red blood over last couple days. Patient
states that the amount of blood she has been coughing has been
increasing and is now almost hourly aprroximately 1 teaspoon
bright red blood. Patient states that the cough DISEASE produced
primarily yellow sputum until it turned to blood. Patient denies
any other symptoms such as dizziness DISEASE or lightheadedness DISEASE . She
denies any changes in her BMs including consistency frequency
and color. Patient visited PCP DISEASE on [**Name9 (PRE) 2974**] and a CXR was
negative. Her was also noted to be subtherapeutic and she took
an extra day of 10 mg warfarin as instructed.
.
Initial vitals in the ED were: 108 138/95 18 100% RA DISEASE . Her HCT
was 29.6 her baseline is unclear but appears to be low 30s. INR
was 4.4. A CTA was done for concern of PE which showed: 1. Left
lower lobe consolidation with large amount of secretions/fluid
within the left lower lobe segmental bronchi. 2. Centrilobular
nodules and ground glass opacities DISEASE throughout both lungs
compatible with chronic collagen vascular disease DISEASE progressed
since [**2191**]. Ground glass opacities DISEASE could also represent
hemorrhage DISEASE . 3. Chronic left lower segmental pulmonary arterial
PE unchanged since [**2191**]. No new acute PE detected to the
subsegmental levels. She was initially admitted to medicine but
then transferred to the ICU.
.
On arrival to the MICU initial vitals were: 110 163/96 20 95%RA.
She is breathing comfortably but complains of pain DISEASE in her chest.
Her EKG was reviewed which did not show changes from her prior.
She also complains of a HA that she says she occasionally
recieves toradol. She has had emesis DISEASE in the ED that looked
dark/possibly coffee ground but currently denies nausea DISEASE .


Past Medical History:
# Lupus rash DISEASE
# Herpes Simplex I - [**12-2**] white lesions DISEASE on the tongue and
buccal mucosa
# Axillary Adenopathy - [**10-2**] biopsied -Admission Date: [**2157-1-5**] Discharge Date: [**2157-1-11**]

Date of Birth: [**2099-12-15**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness DISEASE of breath/Heart failure DISEASE

Major Surgical or Invasive Procedure:
[**2157-1-7**] - Urgent mitral valve repair with triangular resection
of middle scallop of the posterior leaflet and annuloplasty with
a 26-mm [**Company 1543**] 3-D annuloplasty ring.

[**2157-1-5**] - Cardiac Catheterization


History of Present Illness:
Delightful 57 year old female with a history of a myxomatous
mitral valve and mitral regurgitation DISEASE dating back to [**2126**]. She
has been followed for moderate regurgitation and mild pulmonary
hypertension DISEASE with symptom observation and serial
echocardiography. In [**2156-10-24**] she began to develop
shortness of breath DISEASE as well as palpitations DISEASE . Her recent
echocardiogram demonstrated a new partial flail of the posterior
mitral leaflet (probably P2/P3 scallops) with
wide-open MR and new severe pulmonary hypertension DISEASE . Her left
atrial size had not changed in size thus suggesting the acute
nature of her severe mitral regurgitation DISEASE . Given these findings
she has been referred for surgical management. She was
originally seen by Dr. [**Last Name (STitle) 3067**] in clinic on [**2156-12-30**] hoever
developed worsening shortness of breath and heart failure DISEASE
neccessitating an earlier admission for surgery.


Past Medical History:
MR/MVP
HTN DISEASE
Admission Date: [**2196-7-9**] Discharge Date: [**2196-7-28**]

Date of Birth: [**2142-9-13**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Latex / Zanaflex

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
AMS

Major Surgical or Invasive Procedure:
1. Intubation [**7-10**] by ICU team
2. LP [**7-11**] by ICU team
3. Tracheostomy [**7-20**] by Interventional Pulmonology (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3072**])
4. PEG placement [**7-21**] by Gastroenterolgy (Dr. [**Last Name (STitle) **] [**Name (STitle) **])

History of Present Illness:
This is a 53 yo WF with a PMHx of advanced [**1-27**] progressive MS
chronic indwelling foley h/o pe on coumadin who p/f personal
care home with AMS
.
The patient's last admission was [**2196-5-22**] who was admitted for
AMS and acute on chronic lethargy. They dx her with toxic
metabolic encephalopathy DISEASE [**1-27**] to UTI DISEASE and mrsa follicullitis (she
had a dermatomal rash DISEASE ). She was treated with vancomycin she
improved was transitioned to orals bactrim and doxycycline and
was d/c.
.
The following history was obtained from an LPN named [**Name (NI) **]
[**Name (NI) 3073**] at [**Telephone/Fax (1) 3074**]. She states that since the patient
prior admission she never returned to her baseline. The patient
seems to have a waxing and wanning mental status. She denies
seeing the patient have twitching movements DISEASE or signs of
infection DISEASE such as recent diarrhea fever DISEASE or cough DISEASE . Temps at [**Hospital1 1501**]
ranged from 99.2-99.4. The patient recently history is notable
for non-compliance DISEASE both when she is oriented and when she is
not. She refuses UA evalaution and also refuses suprapubic
care. It is not clear when the last time her supr-pubic cath
was changed. Starting the day of admission the patient was
incoherent was unable to swallow her pills and was salivating.
she was deemed usafe to be at her home and was sent to the ED
and [**Hospital1 **].
.
The patient arrived to the ED and was intially minimally
responsive. Per the ED reports she improved while there from a
MS perspective. They did an I and D of the area around her SP
cath and it was sent for culture which showed GPC in pairs and
GPR. BC and Urine cultures were sent. The patient HCT showed
nothing acute and her CXR was wnl. The patient was given
levofloxacin and sent to the floor.

Past Medical History:
1) Multiple sclerosis (advanced secondary progressive)
-followed by Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] in neurology clinic
-diagnosed at age 23
-largely wheelchair bound needs assistance with transfer
-chronic suprapubic catheter changed once monthly
2) History of pulmonary embolism DISEASE on coumadin
3) depression DISEASE
4) hyponatremia DISEASE
5) h/o mrsa
6) h/o c. diff colitis DISEASE
7) h/o intermitent UTI DISEASE 's in the past


Social History:
Non-smoker non-drinker. Lives at [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
Living in [**Location (un) **]. Divorced.


Family History:
NC

Physical Exam:
Admission Physical Exam:
VS BP 140/94 P-64 R-18 SaO2-97 RA DISEASE
General: Patient is able to answer yes and no questions but in
mostly non verbal except [**12-27**] word statements
HEENT: CN 2-12 grossly intact mmm pupils equal and minimally
responsive to light
Endo: no obvious thyroid nodules
CV: RRR no rmg
Lungs: CTAB no WRR
Abdomen: non TTP DISEASE active BS SP cath in place with minimal
erythema DISEASE and milkly residue on inside of tube
Extremities/Neuro:
UE
-some rigidity DISEASE in bue 1Admission Date: [**2169-5-25**] Discharge Date: [**2169-5-31**]

Date of Birth: [**2136-9-18**] Sex: F

Service:
HISTORY OF PRESENT ILLNESS: The patient is a 32 year-old
woman with a recurrent demyelinating illness DISEASE brought to the
Emergency Room by her parents on the recommendation of her
neurologist for evaluation of behavior changes including
increased sexual promiscuity increased spending and
report that she is compulsively wanting to have sexual
activity and unable to control it to the degree that she is
placing herself and her parents at risk. She has contact[**Name (NI) **]
many men by computer and phone. Several nights prior to
admission her father heard noises in the middle of the night
and found a strange man in the patient's bedroom. The father
called the police and the police knew him to be a dangerous
the patient left the house unbeknown to the parents and was
waiting outside for a cab to take her to a motel where she
had arranged a liaison with the same man. The father stated
he had also escorted other strange men out of the house and
is very worried about the patient and the families safety.
She also has had increased spending and has had a progressive
decline in her ability to care for herself including
decreased ambulation. The other stresses beside her
declining physical abilities was that her fiance who was
bipolar DISEASE committed suicide DISEASE by jumping in front of a train in
[**2169-1-20**]. On [**2169-5-11**] she was seen by a neurologist
and an MRI was ordered. The patient was then referred for
evaluation for psychiatric DISEASE admission for behavioral control.

PAST PSYCHIATRIC HISTORY: Admission to [**Hospital1 190**] in [**2164-2-18**] for a psychotic disorder DISEASE with
hallucinations DISEASE secondary to prescribed steroids. In [**2158**] she
was seen by a psychiatrist when her neurological illness DISEASE was
first diagnosed and she started to exhibit disinhibited
behavior and impulsiveness DISEASE with late night phone calls. Her
neuropsychologist is Dr. [**Last Name (STitle) 3085**].

PAST MEDICAL HISTORY: She was diagnosed with a demyelinating DISEASE
illness in [**2158**] which has involved frontal lobe dysfunction DISEASE
and neurogenic bladder as well as difficulty with the
ambulation. She has chronic sinusitis DISEASE . Her primary care
physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3086**]. Her neurologist is Dr. [**Last Name (STitle) 3087**]
and her consulting neurologist at [**Hospital1 190**] is Dr. [**Last Name (STitle) 3088**].

ALLERGIES: Flu shots.

MEDICATIONS ON ADMISSION: Baclofen 820 mg tablets q.d.
Ditropan XL 20 mg q.d. Beconase nasal spray two times a day
ferrous sulfate 325 mg a day Solu-Medrol q.m. intravenous
last dose [**2169-5-4**] next dose scheduled for [**2169-6-1**] and Celexa
20 mg q.d.

SUBSTANCE ABUSE HISTORY: The patient denies.

SOCIAL HISTORY: Both the patient and her 28 year-old brother
were adopted and live with their parents in [**Location (un) 38**]
[**State 350**]. She was six weeks old when she was adopted.
She was an average student with no academic difficulties.
Question of history of sexual assault DISEASE in [**2159-7-21**]. She
graduated from [**Last Name (Prefixes) 3089**] College where she studied early
childhood development. She is single. Never married.

FAMILY PSYCHIATRIC HISTORY: Not available.

LABORATORY DATA ON ADMISSION: CBC and SMA DISEASE were within normal
limits. RPR was negative. HCG was negative. TSH was within
normal limits. Tox screen was negative.

MENTAL STATUS EXAMINATION ON ADMISSION: The patient was
pleasant well groomed and appropriately dressed sitting on a
stretcher. Her attitude was cooperative. Her speech was
articulate. Very matter of fact with little affect. Mood
was depressed DISEASE . Affect minimally reactive. Thought form was
linear and coherent. She denied any preoccupations
obsessions DISEASE and delusions DISEASE except for her thoughts about sex.
She did not appear to have any delusions DISEASE . She denied
suicidal or homicidal ideation DISEASE . Her insight and judgment
were impaired. Her cognitive examination was abnormal in her
inability to do serial sevens. She was able to do serial
threes. She remembered 2 out of 3 in five minutes.
Calculations and fund of knowledge were within normal limits.

HOSPITAL COURSE: The patient was admitted to [**Hospital1 **] Four.
A trial of Depakote ER was begun to help with her impulsive
behaviors. Her family and her outpatient physicians were
contact[**Name (NI) **]. The patient was pleasant and involved in MILU
activities. She did have a fall on the unit with no acute
injuries DISEASE noted and fall precautions were put into place. Her
family met with the inpatient team as well as Dr. [**Last Name (STitle) 3088**] who
reviewed her recent MRI and said that it showed worsening of
her demyelinating disorder DISEASE which could be consistent with
her current change in behavior. He would continue to follow
her. The patient had no further urges or attempts to engage
anyone sexually and was in very good control on the unit.
She did have another fall using her walker and began to use
her wheel chair more frequently. She denies side effects
from the Depakote. On [**5-30**] she complained of an upset
stomach diarrhea DISEASE and a productive cough DISEASE for three days with
some blood in her sputum. She denied any shortness of
breath. Lungs were clear on examination. The patient had an
extensive physical therapy consult and evaluation and further
physical therapy was recommended.

Discharge planning proceeded with the patient agreeing to go
to a brief rehab stay for continued physical therapy before
returning home. On [**2169-5-31**] the patient was being assisted in
transfer from bed to her wheel chair and had a sudden cardiac
and respiratory arrest DISEASE . CPR was initiated and she was
transferred to the Intensive Care Unit.

In the MICU the patient was in pulseless DISEASE electrical activity
(PEA) and was felt to have suffered a massive pulmonary
embolism DISEASE . She was given thrombolysis with restoration of pulse
and blood pressure while being maintained on vasopressors and
mechanical ventilation. However despite maximum supportive
measures hypotension DISEASE became refractory and the patient died
within 24 hours of transfer to the ICU. The patient's family was
notified of the events and was with the patient in her final
hours.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**] M.D.
[**MD Number(1) 3091**]

Dictated By:[**Last Name (NamePattern1) 3092**]

MEDQUIST36

D: [**2169-7-24**] 17:18
T: [**2169-8-1**] 07:09
JOB#: [**Job Number 3093**]
Admission Date: [**2141-7-9**] Discharge Date: [**2141-7-13**]

Date of Birth: [**2095-12-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
overdose DISEASE

Major Surgical or Invasive Procedure:
Intubation


History of Present Illness:
Mr. [**Known lastname 2445**] is a 45 year old man who presented to the [**Hospital1 18**] via
[**Location (un) 86**] EMS. Pt was found by EMS at his home at 10:21pm [**2141-7-8**].
The patient was supine pt was noted to by awake and alert BP
120/88 pulse 72. He was noted to have overdosed taking Admission Date: [**2120-11-15**] Discharge Date: [**2120-11-16**]

Date of Birth: [**2071-12-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Demerol / Zidovudine / Dilaudid / Levaquin

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Found down in apartment by Social Worker

Major Surgical or Invasive Procedure:
None

History of Present Illness:
48 y/o M with PMH of HIV/AIDS last CD4 13 [**8-17**] and VL 51000
[**5-18**] candidal esophagitis peripheral neuropathy DISEASE who presents
after being found down in his apartment. He was brought in my
EMS and intubated in ED due to combativeness and altered mental
status. Further history unable to be obtained from patient or
HCP who was unable to be reached.
.
In the ED VS were rectal T [**Age over 90 **] F BP 104/palp HR 60 RR 16. He
was given etomidate and rocuronium pre-intubation and placed on
propofol gtt. He was given 2L NS and 2L LR as well as 1gm IV
vancomycin and 2gm ceftriaxone. Toxicology was consulted and
recommended charcoal 50gm. he was placed on a bear hugger and
rectal temp came up to 93. He was transferred to the ICU for
further care. On arrival to ICU VS were stable. He was placed
under warming blanket and arterial line was placed.

Past Medical History:
1. HIVAdmission Date: [**2166-10-4**] Discharge Date: [**2166-10-7**]

Date of Birth: [**2094-5-31**] Sex: M


CHIEF COMPLAINT: Sepsis DISEASE and renal failure DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
gentleman with an extensive past medical history including
complicated by persistent respiratory failure DISEASE (on chronic
tracheostomy) hypertension DISEASE restrictive lung disease DISEASE
cardiomyopathy DISEASE and cirrhosis DISEASE who presented with worsening
respiratory status and episodes of hypotension DISEASE .

The patient lives at [**Hospital3 672**] HospitalAdmission Date: [**2129-6-12**] Discharge Date: [**2129-6-14**]

Date of Birth: [**2050-1-17**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Planned Left internal carotid angio/stent

Major Surgical or Invasive Procedure:
Catheterization with left internal carotid stent placement.


History of Present Illness:
Pt is a 79 yo male CAD s/p CABG PVD R Coronary artery DISEASE
stenting systolic CHF DISEASE (EF 45%) CRF DISEASE (creat 1.9) and HTN DISEASE who is
now s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stenting. In [**Month (only) 958**] and [**Name (NI) **] pt had episodes x1 of
LOC. In [**Month (only) 958**] his wife walked into the room to find him
hunched DISEASE over in his chair with Admission Date: [**2140-11-5**] Discharge Date: [**2140-11-18**]

Date of Birth: [**2101-3-21**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old
female with end-stage renal disease DISEASE secondary to diabetes DISEASE .
She also has a history of hypertension DISEASE peripheral vascular
disease and hypothyroidism DISEASE who presented with chest pain DISEASE .

The patient felt chest pressure while walking and had
associated shortness of breath and emesis DISEASE . She did have
relief with rest. On admission she did also note that her
blood sugars were running higher than normal. She did have a
stress test five years ago as a possibility for transplant
option which was normal.

In the Emergency Department the patient was given aspirin
ceftriaxone Lopressor and was chest pain DISEASE free.

PAST MEDICAL HISTORY: (Her past medical history includes)
1. Type 1 diabetes DISEASE with associated retinopathy DISEASE and
neuropathy DISEASE .
2. Hypertension DISEASE .
3. Peripheral vascular disease DISEASE .
4. End-stage renal disease DISEASE (hemodialysis dependent). Her
hemodialysis schedule is on Monday Wednesday and Friday.
5. History of hypothyroidism DISEASE .
6. Status post percutaneous transluminal coronary
angioplasty of the bilateral lower extremities.
7. Status post amputation of her right foot.

SOCIAL HISTORY: The patient moved here from [**State 108**] and
lives with her mother in [**Name (NI) 8**]. She does not smoke. She
does not drink alcohol. She does not use intravenous drugs.
She does ambulate with a cane.

ALLERGIES: The patient has allergies DISEASE to CLINDAMYCIN (which
gives her diarrhea DISEASE ) LEVAQUIN (which gives her
gastrointestinal upset) and ZEMPLAR (which gives her a
rash DISEASE ).

MEDICATIONS ON ADMISSION: (Her medications on admission
included)
1. Plavix 75 mg by mouth once per day.
2. Atenolol 25 mg by mouth once per day.
3. NPH insulin 26 units subcutaneously in the morning with
16 units subcutaneously regularAdmission Date: [**2145-3-11**] Discharge Date: [**2145-3-17**]

Date of Birth: [**2101-3-21**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Clindamycin / Zemplar / Levofloxacin / Trazodone / Doxycycline

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hypotension DISEASE line infection DISEASE

Major Surgical or Invasive Procedure:
IR placement on tunelled HD DISEASE line on [**3-16**]


History of Present Illness:
43F with ESRD DISEASE on HD DM1 DISEASE CAD s/p CABG h/o poor access with
failed AV fistulas DISEASE presenting with pus coming from HD DISEASE line.
Systolic BPs to 80s patient appeared sick and was not mentating
well. Lactate was 3.0. Therefore peripheral dopamine started
(patient did not want central line). She did not have arterial
line. On arrival on the floor hypotensive DISEASE to sbp of 84 but
talkative mentating. says baseline BP is in 110s. Given that
patient does not have dialysis access she was not given IVF.
Pressure has now improved to mid-90s systolic.
Of note patient admitted to [**Hospital1 18**] [**12/2144**] for tunelled line
infection DISEASE . the line was removed and replaced at that time. A
TTE did not show evidence of endocarditis DISEASE at that time. A TEE
was attempted but not completed because of patient intolerance.
She denies known exposure to line site to cause infection DISEASE .
She wonders about sterility of dressings at her outpatient HD DISEASE
center.
Upon arrival at the [**Hospital1 18**] ED patient was febrile DISEASE to 101.5
later peaking at 102.6. Central line considered but patient
refused.

Past Medical History:
1. CAD s/p CABG x 3 in [**10-27**]
2. DM1 DISEASE since age of 6
3. ESRD DISEASE on HD DISEASE being worked up for transplant
4. h/o MRSA rt stump infection DISEASE
5. anemia DISEASE
6. PVD DISEASE s/p TMA DISEASE
7. h/o epistasis from right nostril
8. Bell's Palsy DISEASE (right side s/p valtrex x 7 days last [**1-2**])
9. AAA repair in '[**39**]
10. h/o previous tunelled line infection DISEASE .

Social History:
No tobacco alcohol or illicit drug use

Family History:
Mother: [**Name (NI) 2481**] disease and CAD
Father: deceased from prostate CA
Siblings are all alive and well

Physical Exam:
Exam on transfer to floor

Vitals: T 94.5 84/doppler DISEASE 67 16 98%RA
General: well-appearing
Neck: no JVD
CV: RRR nl S1 S2 no murmurs
Lungs: Crackles at bases bilaterally
Abd: Soft NT ND Admission Date: [**2145-5-17**] Discharge Date: [**2145-5-24**]

Date of Birth: [**2101-3-21**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Clindamycin / Zemplar / Levofloxacin / Trazodone / Doxycycline /
Haldol

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Hypoxia altered mental status

Major Surgical or Invasive Procedure:
HD translumen cath


History of Present Illness:
Ms. [**Known lastname 3123**] is a 44 yoF with DM1 ESRD DISEASE [**12-26**] diabetic nephropathy DISEASE
on HD DISEASE hx MRSA HD line infections DISEASE hx of CABG and AAA repair who
presented to the ED on [**2145-5-17**] with multiple vague complaints.
Patient was reportedly hypoxic confused and febrile DISEASE at her
nursing home. She is anuric so no urine sample was sent. CXR
was clear. Given her h/o AAA she underwent a CT torso with IV
contrast which demonstrated no evidence of PE aortic
dissection or AAA. No parenchymal lung process other than
dependent atelectasis DISEASE and a small right pleural effusion DISEASE . She
was hypotensive DISEASE in the ED but intially responded to fluids. BCx
drawn prior to vancomycin 1gm IV.

Past Medical History:
1. CAD s/p CABG x 3 in [**10-27**]
2. CHF DISEASE - EF 20-25% Severe regional and moderate global LV
systolic dysfunction DISEASE .
3. Mild mitral and tricuspid regurgitation DISEASE .
4. DM1 DISEASE since age of 6
5. ESRD DISEASE on HD DISEASE . Failed R and L AVG now has tunneled HD catheter
LIJ most recently replaced [**3-2**]. Changed from RIJ [**10-31**]. MRSA
infection DISEASE [**1-1**] catheter changed (clot in R IJ) Rx vanc til
[**2145-1-23**]. Then another line change [**3-2**] for infected tunneled
line.
6. h/o MRSA rt stump infection DISEASE
7. anemia DISEASE
8. PVD DISEASE s/p TMA DISEASE
9. h/o epistasis from right nostril
10. Bell's Palsy DISEASE (right side s/p valtrex x 7 days last [**1-2**])
11. AAA repair in '[**39**]
12. h/o previous tunelled line infection DISEASE .

Social History:
No tobacco alcohol or illicit drug use


Family History:
Mother: [**Name (NI) 2481**] disease and CAD
Father: deceased from prostate CA
Siblings are all alive and well

Physical Exam:
Physical Exam:
Vitals: T 98.0 BP: 109/68 HR: 97 RR: 18 SaO2: 99% 2L NC
General: pleasant chronically ill appearing A&Ox3
Neck: Supple. No LAD. JVP Admission Date: [**2113-11-8**] Discharge Date: [**2113-11-22**]

Date of Birth: [**2029-9-9**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
increasing angina DISEASE

Major Surgical or Invasive Procedure:
[**2113-11-9**] CABG x5 (LIMA to LAD SVG to RCA seq. to PDA SVG to
OM SVG to DIAG)
[**2113-11-8**] cardiac cath with IABP

History of Present Illness:
84 yo w/several month h/o exertional DISEASE
shoulder discomfort which is relieved w/NTG. He has had 3 day
h/o
worsening shortness of breath and shoulder pain DISEASE . On admission
he
recieved nitroglycerin and his chest pain DISEASE was relieved. On EKG
he was found to have STD laterally and
apically as well as QW anteriorly as well as positive troponin
with an acute MI.
This pm on the floor the patient developed worsening confusion DISEASE
and hypotension DISEASE . He was taken to the cath lab where he was
found
to have severe left main disease and developed hypotension DISEASE with
injection of the coronary arteries. He required an intra aortic
balloon pump for hemodynamic stabilization and decision was made
to take him emergently to the operating room.


Past Medical History:
Coronary artery disease DISEASE
type 2 diabetes DISEASE
peripheral arterial disease DISEASE
hypertension DISEASE
hyperlipidemia DISEASE
peptic ulcer disease DISEASE
severe GI bleed DISEASE [**2106**]
trigeminal neuralgia DISEASE
Left lumbar radiculopathy DISEASE secondary to degenerative
disc disease DISEASE
Past Surgical History
s/p bilateral CEA
s/p appendectomy
s/p bilat cataract DISEASE surgery


Social History:
The patient lives alone widowed three children. He is now
retired former teacher. He denies alcohol drug. Tobacco use 30
years 1ppd. quit 30 years ago.


Family History:
from OMR: father MI DISEASE at 57. MI in several uncles. Mother
reportedly died from peritonitis DISEASE .

Physical Exam:
Admission Physical Exam
Pulse:86 Resp: O2 sat:
B/P Right: 120/85 Left:
Height: 65Admission Date: [**2178-4-25**] Discharge Date: [**2178-4-30**]

Date of Birth: [**2138-6-3**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Bactrim

Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
etoh withdrawl rhabdomyolysis DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Patient is a 39 yo male with pmhx HIV (unknown cd4 viral
load)on HAART brought in by police after being found down behind
a dumpster. No records available in computer and ED thinks that
pt gets most of his care at [**Hospital1 2177**]. Neurology was initially
consulted for altered mental status which they attributed to
toxic/metabolic issues etoh intoxication UTI DISEASE but recommended
that if he continued to have altered sensorium and not clear
appropriately to consider LP for CNS infection DISEASE and MRI to r/o
toxo PML etc. Head CT was negative. Serum etoh was 229 and he
had an anion gap of 39 on presentation to the ED. He was going
to be admitted to the floor but the floor team asked for
additional studies to work up his anion gap and he was found to
have a lactate of 8. He was given broad spectrum abx including
vancomycin levaquin and ceftriaxone. Toxicology was consulted
and recommended checking an osm gap which was 79 by my
calculation. Toxicology recommended giving IVF and if the
lactate and osmolar gap improved with fluid then it was
unlikely to be due to ethylene glycol or methanol intoxication.
After 5 liters of IV NS lactate decreased from 8--Admission Date: [**2143-11-17**] Discharge Date: [**2143-11-23**]

Date of Birth: [**2096-10-21**] Sex: M

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
47M admitted for liver transplantation. Most recent
hospitalization for R VATS biopsy of a lung nodule concerning
for
metastatic HCC DISEASE .

ROS: denies fevers chills nausea vomiting diarrhea dysuria DISEASE
hematuria DISEASE URI symptoms cough shortness of breath or any
other
pain DISEASE or discomfort

Major Surgical or Invasive Procedure:
Orthotopic liver transplantation done on [**2143-11-19**]


Past Medical History:
HBV
Heptocellular Carcinoma DISEASE s/p RFA DISEASE
Hamartoma DISEASE .
Hypertension DISEASE .


Social History:
Cantonese and has a high school education. He is married and
has
two children ages 15 and 17. He is a restaurant cook.
He has no history of alcohol use. He smoked one pack of
cigarettes per day in the past but quit 10 years ago. He has no
history of IV drug use marijuana
use blood transfusions tattoos or piercing.


Family History:
His family medical history is significant for his mother who is
alive and healthy. His father died of unknown causes.


Physical Exam:
98.4 111 135/98 18 97% RA DISEASE
Gen: NAD
HEENT: EOMI not jaundiced DISEASE mucous membranes moist no cervical
lymphadenopathy DISEASE no supraclavicular lymphadenopathy DISEASE no JVD
Chest: CTAB RRR no M/R/G
Abdomen: soft non-tender non-distended
Extremities: no edema DISEASE 2Admission Date: [**2188-2-8**] Discharge Date: [**2188-3-4**]


Service: MEDICINE

Allergies DISEASE :
Hydralazine

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Admission Date: [**2182-2-18**] Discharge Date: [**2182-2-28**]

Date of Birth: Sex: F

Service:


HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
female with a complex medical history who was admitted after
a cardiac arrest DISEASE on [**2182-2-18**]. She was initially taken to the
CCU thought to be in congestive heart failure DISEASE . Subsequently
developed sepsis DISEASE acute ARDS respiratory-cardiopulmonary
failure. On [**2182-2-28**] at 3:15 p.m. the patient was
pronounced dead. Family was at bedside.

Date of death DISEASE [**2182-2-28**]. Time of death DISEASE 3:15 p.m.



[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 2462**] [**MD Number(1) 2463**]

Dictated By:[**Last Name (NamePattern4) 2464**]
MEDQUIST36
D: [**2182-5-20**] 16:12:18
T: [**2182-5-21**] 01:55:14
Job#: [**Job Number 2465**]
Admission Date: [**2108-5-16**] Discharge Date: [**2108-6-4**]

Date of Birth: [**2033-4-24**] Sex: F

Service: Neurosurgery

HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with a sudden collapse. The daughter immediately
called EMS. The patient was taken to an outside hospital and
was found to have a GCS DISEASE of 5. She was intubated sedated and
transferred to [**Hospital1 69**] for
further evaluation.

MEDICATIONS ON ADMISSION: 1. Lisinopril 40 mg q. day. 2.
Atenolol 12.5 q. day. 3. Celebrex 20 mg q. day. 4. Lasix 20
mg q. day.

PAST MEDICAL HISTORY: Hypertension DISEASE .

HOSPITAL COURSE: The patient's blood pressure at the outside
hospital was in the 190s. She was given Mannitol and blood
pressure was stable on transport. The patient partially
opened her left eye to sternal rub. Pupils were 2 down to 1
mm and brisk. She had positive corneals positive gag. She
localized in the left upper extremity to pain DISEASE flexor
posturing DISEASE in the right upper extremity withdrew bilateral
lower extremity left greater than right.

Head CT showed a large intraventricular hemorrhage DISEASE with
casting of the left lateral ventricle blood surrounding the
edema DISEASE causing shift of midline structures. She was taken
emergently to the operating room for a left frontal
craniotomy for evacuation of the hematoma DISEASE .

Upon arrival to the trauma DISEASE surgical intensive care unit
postoperatively the patient was sedated on propofol. She was
lightened for examination. Her pupils were 2 mm and brisk.
Her right corneal was impaired her left was intact. Gag was
absent. Cough was intact. She did not respond to verbal
stimuli withdrew bilateral lower extremities to painful
stimuliAdmission Date: [**2125-2-1**] Discharge Date: [**2125-2-19**]


Service: MEDICINE

Allergies DISEASE :
Ultram

Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Hematuria cough abdominal pain DISEASE

Major Surgical or Invasive Procedure:
IVC filter placement


History of Present Illness:
85 F h/o stage 0 CLL DISEASE not requring tx previously presents to ED
for persistent cough/abdominal pain DISEASE and hematuria DISEASE .
.
Pt notes about 2 months of increasing fatigue DISEASE nightsweats
decreased appetite and increasing left side abdominal pain DISEASE
(intermittent no relation to food BM sharp no diarrhea DISEASE
constipation melena DISEASE ). She was seen by PCP [**2125-1-9**] felt to have
viral URI symptoms persisted and seen again [**2125-1-23**] with
persistent cough DISEASE (intermittently productive yellow-white)
single episode of hematuria DISEASE (clear red not clot) and LLQ
abdominal pain DISEASE treated with azithromycin and abdominal US
obtained which revealed new splenomegaly DISEASE with new 1.5-cm
echogenic area.

On [**1-31**] pt noted recurrent episode of Admission Date: [**2145-9-20**] Discharge Date: [**2145-9-26**]

Date of Birth: [**2093-1-29**] Sex: M

Service: Thoracic surgery

HISTORY OF PRESENT ILLNESS: Patient is a 52 year-old male
with history of atrial fibrillation DISEASE who had experienced
presumed onset of chest pain DISEASE over the past few weeks. He did
not complain of any chest pain DISEASE at rest. He has used
sublingual nitroglycerin the past. Patient was admitted to
an outside hospital with the increased symptoms. He
underwent stress test in [**2145-9-1**] which showed diffuse
ST depression DISEASE thus he was transferred to the [**Hospital1 346**] for further evaluation and possible
coronary artery revascularization.

PAST MEDICAL HISTORY: Is significant for hypertension DISEASE a
former smoker and depression DISEASE . He has no known drug
allergies DISEASE . His medications at home include Lopressor
Coumadin for paroxysmal atrial fibrillation DISEASE aspirin.

PERTINENT LABORATORY DATA: His hematocrit was 38.6
BUN/creatinine 11/1.0.

HOSPITAL COURSE: Patient was admitted to the cardiology
service and he underwent cardiac catheterization on [**2145-9-20**]
which showed an ejection fraction of approximately 67 percent
and 90 percent discrete mid-LAD stenosis DISEASE with 60 percent
proximal circumflex and 60 percent OM2 stenosis. Patient was
referred to Dr. [**Last Name (STitle) 1537**] for revascularization. He underwent off
pump coronary artery bypass graft times two on [**2145-9-22**]. He received a LIMA graft to the LAD and saphenous vein
graft to the LAD and saphenous vein graft to the OM1. He
tolerated the procedure well without any complications and
was transferred to the Cardiac Intensive Care Unit in stable
condition. He was extubated postoperatively and was
transferred to the floor on postoperative day one. Physical
therapy was consulted and patient was noted to be doing
extremely well with ambulation. On postoperative day one
patient did experience atrial fibrillation DISEASE which was
controlled with intravenous Lopressor Amiodarone and
diltiazem drip. He was noted to convert to a normal sinus
rhythm on postoperative day two. The diltiazem drip was
discontinued and Amiodarone was converted to oral dose. On
postoperative day three he again was ambulating extremely
well. He was noted to clear level 5 with the physical
therapist and was able to [**Last Name (un) 3180**] and down stairs. He
remained afebrile with stable vital signs. His pulse was 71
blood pressure was 105/61 and he was maintained on Lopressor
75 mcg p.o. b.i.d. and Cardizem CD 80 mg q.d. and Amiodarone.
Patient is currently postoperative day four and is being
discharged home in stable condition.

DISCHARGE DIAGNOSIS:
Coronary artery disease DISEASE status post off pump coronary artery
bypass graft times two.

DISCHARGE MEDICATIONS: Include Lopressor 75 mg p.o. b.i.d.
Lasix 20 mg p.o. b.i.d. times three days KayCiel 20 mEq p.o.
b.i.d. times three days aspirin 81 mg p.o. q.d. Plavix 75
mg. p.o. q.d. Amiodarone taper 400 mg p.o. t.i.d. times five
days then b.i.d. times seven days then 200 mg p.o. q.d.
Cardizem CD 180 mg p.o. q.d. Percocet 1 to 2 pills q 4 to 6
hours and Colace 100 mg p.o. b.i.d.

DISCHARGE MEDICATIONS: 1) Patient is to continue taking all
his medications. 2) He should follow up with Dr. [**Last Name (STitle) 1537**] and
his primary care physician in approximately three week. 3)
Regarding patient's Coumadin dose for paroxysmal atrial
fibrillation DISEASE patient is currently managed with Amiodarone.
He will be treated with Plavix for the next three to six
months and after Plavix is discontinued patient should resume
his Coumadin. Patient is not recommended to be both on
Plavix and Coumadin as hemostasis will be completely
disrupted. The patient should follow up closely with his
primary care physician and his cardiologist.




[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**] M.D. [**MD Number(1) 1540**]

Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36

D: [**2145-9-26**] 11:17
T: [**2145-9-26**] 12:23
JOB#: [**Job Number 3182**]
Admission Date: [**2166-8-25**] Discharge Date: [**2166-8-27**]


Service: [**Hospital Unit Name 196**]

Allergies:
Prednisone

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
amaurosis fugax DISEASE and syncope DISEASE

Major Surgical or Invasive Procedure:
L Internal carotid artery stent placement.

History of Present Illness:
82 yo Male with symptomatic [**Doctor First Name 3098**] stenosis admitted to CCU after
carotid stent placement. Pt has severe vascular disease DISEASE - 90%
[**Doctor First Name 3098**] stenosis 30-60% [**Country **] stenosis CAD - NQWMI in [**2-11**] (found
2VD - 70% ostial RCA TO LCx distally with collateral flow). Pt
also has PVD DISEASE and Admission Date: [**2166-12-22**] Discharge Date: [**2166-12-27**]


Service:


Transferred to the vascular service under the care of Dr.
[**Last Name (STitle) **] on [**2166-12-23**].

CHIEF COMPLAINT: Claudication.

HISTORY OF PRESENT ILLNESS: This is an 82-year-old gentleman
of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3185**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who has a history
of peripheral vascular disease DISEASE and renal artery stenosis DISEASE who
was referred for intervention for his peripheral vascular
disease.

HISTORY OF PRESENT ILLNESS: The patient had a cardiac
catheterization on [**2164-2-28**] for progressive dyspnea DISEASE .
The findings at that time demonstrated the left main was
normal. The anterior descending proximally was scattered
mild limb irregularities. The circumflex also had mild
irregularities proximally and was totally occluded distally
with bridging collaterals and septal collateral flow to the
distal vessel and left PDA. The right coronary was non-
dominant with an ostial lesion of 70%. The patient also was
known to have carotid disease DISEASE with symptomatic left internal
carotid artery stenosis DISEASE . He underwent a precise stent
placement on [**2166-8-25**]. He was also found to have an
80% focal lesion of the left renal artery and severe right
common femoral artery disease DISEASE . On [**11-7**] he had a
peripheral arteriogram for progressive claudication. His was
found to have bilateral iliac disease DISEASE with severe right
common femoral disease DISEASE and occluded left common femoral
artery and bilateral SFA occlusions. Attempts to cross the
left common femoral stenosis DISEASE into the PFA failed.

An MRI was done on [**2166-11-21**] showed symmetrical
peripheral vascular disease DISEASE with longstanding segmental
occlusions at both superficial femoral arteries and posterior
tibial arteries. A 3.4 cm occlusion of the left common
femoral artery. The patient was referred for renal
arteriogram and intervention. The patient has left greater
than right claudication DISEASE at walking at 100 feet.

PAST MEDICAL HISTORY: Prednisone causes agitation DISEASE .

MEDICATIONS ON ADMISSION: Included Lasix 20 mg daily Imdur
30 mg daily Proscar 5 mg daily glyburide 2.5 mg daily
captopril 25 mg b.i.d. Plavix 75 mg daily aspirin 325 mg
daily simvastatin 10 mg daily amitriptyline 10 mg daily
Serevent Diskus 50 mcg b.i.d. Albuterol and Atrovent inhalers
p.r.n. Flovent 220 mcg b.i.d. albuterol nebs 0.83% and
ipratropium 0.02% nebs q.i.d.

MEDICAL HISTORY: He has a history of syncope DISEASE known
peripheral vascular disease DISEASE known carotid disease DISEASE with a
history of amaurosis fugax DISEASE history of glaucoma DISEASE history of
COPD DISEASE O2 dependent. He requires 1.5 liters with activities
and 3 liters at night. He is a non-insulin type 2 diabetic DISEASE .
He has common bile duct stones DISEASE . He has a benign nodule which
was removed from his lung in [**2159**]. Other surgeries include
bilateral cataract DISEASE surgery in [**2161**] appendectomy at the age
of 52.

SOCIAL HISTORY: Is married for 55 years and is a retired
carpenter.

His family history is positive for pulmonary embolus DISEASE .

HOSPITAL COURSE: The patient was admitted to the cardiac
holding area. He underwent an attempted catheterization by
Dr. [**First Name (STitle) **] on [**2166-12-22**]. They were not able to
angioplasty the left common femoral and arteriogram and
selective renal angiography were done. Vascular service was
consulted that day. His pulse exam was biphasic femorals
popliteals bilaterally with monophasic DP and PT on the left
and absent DP on the right with a monophasic PT on the right.

The patient underwent on [**2166-12-24**] a left common
femoral artery endarterectomy and patch angioplasty. He
tolerated the procedure well. He had a monophasic DP and PT
at the end of the procedure. He was transferred to the PACU
in stable condition. He then was transferred to the VICU for
continued monitoring and care.

Postoperative day #1 the patient will had no overnight
events. His pulse exam remained unchanged. His IV fluids
were hep-locked DISEASE . His diet was advanced as tolerated and
ambulation was begun. The patient was evaluated by physical
therapy who felt that he would be safe for discharge home
with wife and recommended home safety evaluation.

The patient was discharged to home on [**2166-12-27**]. His
foot was warm. His Foley was discontinued prior to discharge
and he had no difficulty with voiding. He should follow up
with Dr. [**Last Name (STitle) **] in two week's time. Follow up with Dr.
[**First Name (STitle) **] in 1 month's time. He should continue his
preadmission medications.

DISCHARGE DIAGNOSIS:
1. Bilateral femoral occlusive disease DISEASE attempted angioplasty
failed status post left common femoral endarterectomy
with patch angioplasty.
2. History of chronic obstructive pulmonary disease DISEASE O2
dependent stable.
3. Type 2 diabetes DISEASE on oral agents controlled.
4. Hypertension DISEASE controlled.
5. Hyperlipidemia DISEASE treated.
6. Renal artery stenosis DISEASE .
7. Carotid artery disease DISEASE status post stent placement of the
left internal carotid artery.
8. History of glaucoma DISEASE .
9. History of the bile duct stones.
10. Status post bilateral cataract DISEASE surgeries.
11. Status post cholecystectomy.
12. Status post benign lung nodule excision in [**2159**].
13. Status post appendectomy at age 52.




[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 3186**]

Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2167-4-9**] 12:10:48
T: [**2167-4-11**] 09:16:20
Job#: [**Job Number 3187**]
Admission Date: [**2179-8-5**] Discharge Date: [**2179-8-30**]

Date of Birth: [**2120-1-7**] Sex: F

Service: ORTHOPAEDICS

Allergies DISEASE :
Aspirin / Nsaids

Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Bilateral pneumonia DISEASE

Major Surgical or Invasive Procedure:
Bilateral Chest tubes placed by VATS
Intubation and ventilation


History of Present Illness:
59F with past medical history significant for chronic steroid
use due to lichen planus degenerative disk disease DISEASE with spinal
stenosis on chronic narcotics hypertension diabetes DISEASE iron
deficiency anemia DISEASE presents with severe RUQ pain DISEASE that was
pleuritic radiating to right shoulder at [**Hospital3 **]. Given
total of 10 mg dilaudid between 3-6pm for pain DISEASE subsequently
developed desaturation DISEASE to 85% on room air-Admission Date: [**2179-8-5**] Discharge Date: [**2179-8-29**]

Date of Birth: [**2120-1-7**] Sex: F

Service: ORTHO


This 59-year-old female was transferred from Medicine Service
after acute treatment for empyema DISEASE . She was medically
controlled with Vancomycin and completed a course for her
acute pneumonia DISEASE .

It was noted that she developed spondylitis DISEASE involving the L4-
5 interspace a level where a previous posterior spinal fusion
without instrumentation had been performed.

PROCEDURE: An anterior retroperitoneal left flank approach
was performed with debridement of the L4-5 spondylitic disc space
and interbody fusion with iliac crest bone graft autogenous and
allograft bone.

HOSPITAL COURSE: She was transferred from the Medicine service
after completing a course for acute pneumonia DISEASE . Her new pain DISEASE
due to the spondylitis DISEASE was treated with the above mentioned
surgery.

Postoperatively her incision healed and her preoperative
pain DISEASE from the spinal condition the infection DISEASE resolved. She
had expected incisional pain DISEASE and the Chronic Pain DISEASE Service
assisted in managing her pain DISEASE issues.

She mobilized to ambulation with a TLSO brace DISEASE and oral pain DISEASE
medication alone.

She resumed normal bowel and bladder function.

She was discharged to rehabilitation facility.

The brace should be worn whenever she is ambulating but can
be off for sitting lying down in bed and toileting. She may
shower and evaluation for home services should be made.

Her medications are included in a list which is to long to
dictated at this time. This is deferred due to accuracy
concerns.

She will up with Dr. [**Last Name (STitle) 363**] in 10 to 14 days.

At a later time consideration for flat back syndrome
correction with posterior spinal osteotomy will be made.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**] [**MD Number(1) 3192**]

Dictated By:[**Last Name (NamePattern1) 3193**]
MEDQUIST36
D: [**2179-8-29**] 14:33:42
T: [**2179-8-29**] 15:38:35
Job#: [**Job Number 3194**]
Admission Date: [**2170-7-29**] Discharge Date: [**2170-8-2**]

Date of Birth: [**2101-5-19**] Sex: F

Service: SURGERY

Allergies DISEASE :
Sulfonamides

Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
Abdominal pain DISEASE

Major Surgical or Invasive Procedure:
[**2170-7-29**] Exploratory Laparotomy Splenectomy

History of Present Illness:
69-year-old female who has had abdominal pain DISEASE for some time.
She
presented with dizziness abdominal pain hypotension DISEASE and
bradycardia DISEASE at the [**Hospital1 18**] Emergency room essentially in
shock DISEASE . On CT scan she was found to have a ruptured spleen
with layering of hemorrhage DISEASE consistent with a large
hemoperitoneum DISEASE . Hematocrit on arrival was 20.3 and she was
requiring pressor support as well as volume. As such
emergency laparotomy was indicated.

Past Medical History:
paroxysmal atrial fibrillation breast cancer DVT DISEASE previously on
coumadin (several years ago) PE hypothyroidism DISEASE chronic
leukopenia anemia DISEASE peripheral neuropathy depression DISEASE HTN HLD
hyponatremia DISEASE BCC
PSH DISEASE :
lumpectomy '[**62**] hip replacement b/l lumbar diskectomy
Meds:


Social History:
Married

Family History:
Noncontributory

Pertinent Results:
[**2170-7-29**] 11:45PM PO2-527* PCO2-34* PH-7.26* TOTAL CO2-16* BASE
XS--10
[**2170-7-29**] 11:45PM LACTATE-1.6
[**2170-7-29**] 11:38PM GLUCOSE-160* UREA N-13 CREAT-0.5 SODIUM-133
POTASSIUM-2.8* CHLORIDE-109* TOTAL CO2-16* ANION GAP-11
[**2170-7-29**] 11:38PM ALT(SGPT)-31 AST(SGOT)-34 ALK PHOS-46 TOT
BILI-0.6
[**2170-7-29**] 11:38PM WBC-13.3* RBC-4.36# HGB-13.3# HCT-38.6#
MCV-88 MCH-30.4 MCHC-34.4 RDW-14.7
[**2170-7-29**] 11:38PM PLT COUNT-98*
[**2170-7-29**] 11:38PM PT-13.9* PTT-26.7 INR(PT)-1.2*
[**2170-7-29**] 07:40PM ALT(SGPT)-11 AST(SGOT)-14 ALK PHOS-44 TOT
BILI-0.2
[**2170-7-29**] 07:40PM LIPASE-11
[**2170-7-29**] 07:40PM ALBUMIN-2.8*

IMPRESSION:
1. Splenic rupture DISEASE with large hemoperitoneum DISEASE . Subcentimeter DISEASE foci
of
hyperdensity in the left upper quandrant with progressive
increased
conspicuity on venous and delayed phases favor nonarterial
etiology although active arterial extravasation cannot be
excluded.

2. Two right lower lobe pulmonary nodules measuring 5 and 2.5
mm. In the
setting of breast cancer DISEASE followup in three months is
recommended. Probable post radiation treatment changes of right
anterior lung subpleural thickening.

3. Multiple foci of sclerosis within the bony pelvis may
represent bone
islands however in the absence of priors metastatic lesions
cannot be
excluded in the setting of breast cancer DISEASE . Recommend comparison
to any prior outside studies. Consider bone scan if these
findings have not already been evaluated.

4. No evidence of abdominal aortic aneurysm DISEASE . Extensive
atherosclerotic DISEASE
disease.

5. Nonspecific breast calcifications DISEASE . Please correlate with
mammography



Brief Hospital Course:
She was admitted to the ACS DISEASE service and after discussing the
risks benefits and alternatives to emergency laparotomy and
possible splenectomy with the patient and the patient's family
she was immediately and emergently taken to the OR. Her
intraoperative course was stable. Postoperatively she was
transferred to the ICU for close monitoring. She remained
hemodynamically stable and was eventually transferred to the
regular nursing unit where she continued to progress.

She did have pain DISEASE control issues requiring higher doses of
Dilaudid DISEASE as she reported an allergy DISEASE to Oxycodone. She was noted
to have a mild ileus DISEASE felt secondary to the narcotics and was
given a 1 time dose of methylnaltrexone. Her diet was slowly
advanced and she is tolerating a regular diet. She is ambulating
independently.

She received her splenectomy vaccines prior to discharge and
will follow up with Dr. [**Last Name (STitle) **] in Surgery clinic in the next
1-2 weeks for removal of her staples.


Medications on Admission:
ARMOUR THYROID 60 MG TABS (THYROID) 2 and [**11-25**] by mouth one time
daily
ASA 81' valsartan 80' triamterene-hctz 75-50' OMEGA-3 1000 MG
CAP' FLECAINIDE 125'' fluvastatin XL 80' nifedipine XL 30'
KCl 10 mEq' vit D [**2159**] IU' COENZYME Q10 400' FOLATE 400MCG'
melatonin 1 qhs prn diazepam 5'prn


Discharge Medications:
1. Thyroid (Pork) 90 mg Tablet Sig: One (1) Tablet PO once a
day: take with 60 mg tablet to equal 150 mg.
Disp:*30 Tablet(s)* Refills:*2*
2. Thyroid (Pork) 60 mg Tablet Sig: One (1) Tablet PO once a
day: take with 90 mg tablet to equal 150 mg tablet.
Disp:*30 Tablet(s)* Refills:*2*
3. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Flecainide 50 mg Tablet Sig: 2.5 Tablets PO Q12H (every 12
hours).
5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain DISEASE .
Disp:*60 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain DISEASE .
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation DISEASE .
9. Pantoprazole 40 mg Tablet Delayed Release (E.C.) Sig: One
(1) Tablet Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet Delayed Release (E.C.)(s)* Refills:*2*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation DISEASE .
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Splenic rupture

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
You are being discharged on medications to treat the pain DISEASE from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.





Please call your doctor or return to the emergency room if you
have any of the following:


* You experience new chest pain DISEASE pressure squeezing or
tightness.

* New or worsening cough DISEASE or wheezing DISEASE .

* If you are vomiting DISEASE and cannot keep in fluids or your
medications.

* You are getting dehydrated due to continued vomiting diarrhea DISEASE or other reasons. Signs of dehydration DISEASE include dry mouth DISEASE rapid heartbeat or feeling dizzy or faint when standing.

* You see blood or dark/black material when you vomit DISEASE or have a
bowel movement.


* You have shaking chills DISEASE or a fever DISEASE greater than 101.5 (F)
degrees or 38(C) degrees.

* Any serious change in your symptoms or any new symptoms that
concern you.

* Please resume all regular home medications and take any new
meds
as ordered.

Activity:
No heavy lifting of items [**9-7**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion no abdominal exercises.

Wound Care:
You may shower no tub baths or swimming.

If there is clear drainage from your incisions cover with
clean dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain swelling DISEASE
redness or drainage from the incision sites.


Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**11-25**] weeksAdmission Date: [**2139-8-20**] Discharge Date: [**2139-8-23**]

Date of Birth: [**2076-7-31**] Sex: M

Service:

CHIEF COMPLAINT: (Per patient) Mitral valve regurgitation DISEASE
noted on yearly physical examination.

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3203**] is a 63 year old
male otherwise healthy who was found to have a systolic
workup. Workup revealed mitral regurgitation DISEASE approximately
two years ago. He had been followed serially with
electrocardiograms and was noted to have worsening valvular dysfunction DISEASE recently. He had a cardiac catheterization in
[**2139-7-6**] which showed normal coronaries ejection
fraction was 66% he had 4Admission Date: [**2139-8-20**] Discharge Date: [**2139-8-23**]

Date of Birth: [**2076-7-31**] Sex: M

Service:

CHIEF COMPLAINT: (Per patient) Mitral valve regurgitation DISEASE
noted on yearly physical examination.

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3203**] is a 63 year old
male otherwise healthy who was found to have a systolic
workup. Workup revealed mitral regurgitation DISEASE approximately
two years ago. He had been followed serially with
electrocardiograms and was noted to have worsening valvular dysfunction DISEASE recently. He had a cardiac catheterization in
[**2139-7-6**] which showed normal coronaries ejection
fraction was 66% he had 4Admission Date: [**2182-2-18**] Discharge Date: [**2182-2-28**]

Date of Birth: [**2109-8-28**] Sex: F

Service:


HISTORY OF PRESENT ILLNESS: The patient was a 73-year-old
female admitted to the CCU on [**2182-2-18**] with hyperkalemia DISEASE and
bradycardia DISEASE . The patient had a past medical history
significant for hypertension glaucoma DISEASE and breast cancer DISEASE
treated with lumpectomy XRT in [**2176**]. She was in her usual
state of health until [**12-2**] when she began to note shortness DISEASE
of breath. She saw her PCP and performed [**Name Initial (PRE) **] chest x-ray
which revealed a right upper lobe density. This was followed
up with a CT scan which revealed a lobulated mass of 2.3 cm
in the posterior segment of the right lower lobe and
bilateral lobe interstitial fibrosis DISEASE . Follow-up PET scan was
nondiagnostic. The patient had a mediastinoscopy which
showed no evidence of malignancy DISEASE or lymph nodes. Lung biopsy
was performed which revealed pulmonary fibrosis DISEASE . Subsequent
spirometry revealed a mild restrictive defect. The entire
picture was thought to represent UIP.

On [**2182-2-18**] she presented to the [**Hospital1 **]
[**First Name (Titles) 2142**] [**Last Name (Titles) **] with a complaint DISEASE of nausea vomiting DISEASE and
diarrhea DISEASE times several days. In the waiting room she
developed presyncope DISEASE . She was urgently brought to the trauma DISEASE
bay there her heart rate was in the 30s with the EKG
revealing a junctional rhythm. Her SBP was in the 80s.
Attempts made to place a temporary pacing wire but during the
procedure the patient suffered respiratory arrest DISEASE . She was
intubated and resuscitated and a line was successfully
placed. Subsequent labs revealed a potassium of 9.8. The
patient was treated with calcium bicarb insulin and glucose
and admitted to CCU.

In the CCU the patient was started on Levophed and dopamine
for hypotension DISEASE . Swan-Ganz catheter was placed to evaluate
her hypotension DISEASE and revealed an SVR of 2473 with a cardiac
output of 2.2. Two hours later the cardiac output was 6.5
and SVR was 898 after pressors were weaned down. Urgent TTE
revealed normal systolic function no pericardial effusion.
Potassium dropped to 4.3 after 1 day. The patient was
empirically treated with vancomycin levofloxacin and Flagyl
for hypotension DISEASE which was thought possibly due to sepsis DISEASE .
By hospital day 3 she was off pressors her white blood
count was 16.1. She was successfully extubated and her
potassium remained normal. By hospital day 4 she continued
to have mild respiratory distress DISEASE despite being extubated.
She was thought to be in mild CHF DISEASE . She was diuresed.
Levofloxacin and vancomycin were continued for possible
pneumonia DISEASE . By hospital day 5 she developed worsening
respiratory distress DISEASE and the patient agreed to elective
intubation. She was then transferred to the MICU for further
workup and care.

PAST MEDICAL HISTORY: Hypertension DISEASE .

Glaucoma DISEASE .

Breast cancer DISEASE .

UIP.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS ON ADMISSION:
1. Verapamil.
2. Propranolol.
3. Tamoxifen.
4. Xalatan eye drops.
5. Betoptic eye drops.
6. Calcium carbonate.
7. Aspirin.
8. Folate.
9. Vitamin E.


PHYSICAL EXAMINATION: On admission to the MICU temperature
98.9 degrees blood pressure 126/61 and pulse 108. The
patient was sedated and intubated. Her lungs revealed
diffuse crackles bilaterally. Cardiac exam was within normal
limits. Abdomen was benign. Lower extremity revealed no
edema DISEASE .

PERTINENT LABORATORY DATA: On admission to the MICU included
a white count of 21.9 hematocrit of 29.3 and platelets of
85.

Chest x-ray on admission to MICU revealed persistent
bilateral upper lobe patchy opacities DISEASE may represent
interstitial edema DISEASE plus aspiration. Continued patchy
atelectasis within the left lower lobe and small left pleural
effusion.

CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Medical Intensive Care Unit with presumed diagnosis of
sepsis DISEASE . Subsequently she developed a picture consistent
with ARDS DISEASE and required multiple pressors. After several days
in the CCU she was on 3 different pressors and was unable to
maintain her blood pressure. She was requiring increasing
ventilatory support. A discussion was held with the family
who decided that the patient will be made DNI/DNR due to the
fact that CPR was likely to be unhelpful if the patient
arrested. On [**2182-2-28**] at 03:15 p.m. the patient was
pronounced dead. The family was at the bedside.

CONDITION ON DISCHARGE: Expired.

DISCHARGE STATUS: Expired.

DISCHARGE MEDICATIONS: None.

FOLLOW UP PLAN: None.

DISCHARGE DIAGNOSES: Septic shock DISEASE .

Respiratory failure DISEASE .

Hyperkalemia DISEASE causing cardiopulmonary arrest DISEASE .



DR.[**Last Name (STitle) 2466**][**First Name3 (LF) 2467**] 12-746

Dictated By:[**Last Name (NamePattern4) 2464**]
MEDQUIST36
D: [**2182-6-21**] 16:34:53
T: [**2182-6-21**] 19:31:08
Job#: [**Job Number 2468**]
Admission Date: [**2120-8-14**] Discharge Date: [**2120-8-19**]

Date of Birth: [**2059-6-19**] Sex: F

Service: Neurosurgery

HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
female with a history of brain tumor DISEASE . MRI scan showed right
cerebellar mass.

PAST MEDICAL HISTORY: Past medical history includes breast
cancer DISEASE with lumpectomy in [**2114**] carpal tunnel syndrome sleep
apnea gastroesophageal reflux disease DISEASE .

PAST SURGICAL HISTORY: Previous surgery included lumpectomy
in [**2114**] hysterectomy in [**2114**] thyroid nodule excision.

ALLERGIES: The patient had no known drug allergies DISEASE .

PHYSICAL EXAMINATION ON ADMISSION: On physical examination
this was an obese woman in no acute distress. HEENT was
anicteric. A well-healed incision. Chest was clear to
auscultation. Cardiac revealed S1 and S2 a regular rate and
rhythm. Abdomen was obese soft a well-healed midline
incision. Extremities revealed slight edema DISEASE of the bilateral
lower extremities nonpitting easily palpable dorsalis pedis
and posterior tibialis pulses.

HOSPITAL COURSE: The patient was admitted on [**2120-8-14**] status post right suboccipital craniotomy for resection
of cerebellar mass DISEASE . There were no intraoperative
complications.

Postoperatively the patient was monitored in the Surgical
Intensive Care Unit where she was awake alert and oriented
times three moved all extremities with good strength. No
drift. Lungs were clear to auscultation. A regular rate and
rhythm.

The patient was transferred to the regular floor on
postoperative day one in stable condition. Her face was
symmetric. Extraocular movements DISEASE were full. Followed 3-step
commands awake alert and oriented times three. The
patient was seen by Physical Therapy and found to require
three to four days of Physical Therapy treatment prior to
discharge to home. The patient did receive that treatment
and is now stable for discharge home.

MEDICATIONS ON DISCHARGE: Her medications at the time of
discharge were Decadron taper off over two weeks time
Percocet one to two tablets p.o. q.4h. p.r.n Zantac 150 mg
p.o. b.i.d. She is also on Lopressor 50 mg p.o. b.i.d.

DISCHARGE DISPOSITION: Vital signs were stable and the
patient was afebrile at the time of discharge.

DISCHARGE FOLLOWUP: The patient was to follow up in the
Brain [**Hospital 341**] Clinic in one week for staple removal and follow
up in the Brain [**Hospital 341**] Clinic with Dr. [**First Name (STitle) **].

CONDITION AT DISCHARGE: Her condition was stable at the time
of discharge.



[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**] M.D. [**MD Number(1) 343**]

Dictated By:[**Last Name (NamePattern1) 344**]

MEDQUIST36

D: [**2120-8-19**] 10:01
T: [**2120-8-21**] 13:47
JOB#: [**Job Number 3206**]
Admission Date: [**2121-8-1**] Discharge Date: [**2121-8-5**]

Date of Birth: [**2059-6-19**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
right handed African-American woman with metastatic breast cancer DISEASE to the brain. She is status post a resection of the
right cerebellum metastasis DISEASE by Dr. [**First Name (STitle) **] on [**2120-8-14**] and was
followed by stereotactic radiosurgery. Spinal tap was done
in [**2120-9-16**] but the cytology was negative. A chest CT
revealed pulmonary metastases DISEASE and she has been treated with
chemotherapy since [**2120-10-17**]. The patient developed
symptoms of loss of balance slurred speech DISEASE and double
vision. An MRI was done which revealed cerebellum metastasis DISEASE
and possible leptomeningeal spread. A chest x-ray from
[**2121-7-1**] showed an increase in lung nodules.

PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 148/84 pulse 84 respiratory
rate 18 temperature 96.6Admission Date: [**2118-9-9**] Discharge Date: [**2118-9-14**]

Date of Birth: [**2050-12-3**] Sex: F

Service: MEDICINE

Allergies DISEASE :
aspirin / amlodipine / Benadryl

Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
Hypotension DISEASE requiring ICU admission

Major Surgical or Invasive Procedure:
Endoscopy


History of Present Illness:
67yo F w/ Uterine carcinosarcoma DISEASE s/p XRT/surgery sent to the ED
from [**Hospital **] clinic because of low BPs. Acute onset of
nausea/vomiting. No fevers/chills/abdominal pain/neck stiffness.
Hypotensive DISEASE to 64/22 in the ED. No pericardial effusion DISEASE . Admission Date: [**2128-3-14**] Discharge Date: [**2128-3-23**]


Service: NEUROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
large intraparenchymal bleed DISEASE


Major Surgical or Invasive Procedure:
None

History of Present Illness:
Patient is a [**Age over 90 **] yo woman with PMH of dementia obesity OA DM2 DISEASE
HTN cataracts DISEASE falls CRF Anemia DISEASE DNR/DNI and active UTI who
suffered a fall at [**Hospital 100**] Rehab today. She is primarily Russian
speaking but also speaks some English. She was heard to fall
in the bathroom at 0800. Patient denied LOC and was without any
apparent injury. She was put back in bed. some time
thereafter she was noted to have dysarhtira left facial droop
and flaccid left hemiparesis DISEASE in the left arm. She was
transfered to [**Hospital1 18**] for presumed CVA DISEASE .

She reports to me that she fell and endorses pain DISEASE in her head
and her lower back. She endorses that she fell around the time
of the pain DISEASE but she cannot communicate the exact sequence of
events.

At baseline she is demented but very active walking with walker
and conversant. She has recently been getting treatment for UTI DISEASE
with Levaquin. Her proxy [**Name (NI) 3535**] reports that her family noticed
some mild speech impairments DISEASE last week but no focal weakness.
This however was around the time of the positive UA and may have
been related to infection DISEASE .

ROS: she is unable to offer full ROS. She is known to have
acitve UTI DISEASE and she does endorse headache DISEASE and LBP DISEASE .


Past Medical History:
dementia obesity OA DM2 HTN cataracts DISEASE falls CRF Anemia DISEASE


Social History:
She lives at [**Hospital 100**] Rehab. Her proxy is relative [**Name (NI) 3535**]
[**Name (NI) 5148**] who can be reached at [**Telephone/Fax (1) 5149**]. Cell:
[**Telephone/Fax (1) 5150**].

Family History:
N/c

Physical Exam:
T- 98 BP- 142-173/53-80 HR- 72 RR- 14 O2Sat 100 2l
Gen: Lying in bed NAD
HEENT: NC/AT moist oral mucosa
Neck: Cervical collar in place
Back: No skin changes. No point tenderness entire spine and
pelvis.
CV: RRR Nl S1 and S2 moderate soft ejection murmur.
Lung: Clear to auscultation bilaterally
aBd: Admission Date: [**2107-7-19**] Discharge Date: [**2107-7-27**]

Date of Birth: [**2070-10-23**] Sex: F

Service: GYN

Allergies DISEASE :
Flagyl

Attending:[**First Name3 (LF) 5158**]
Chief Complaint:
Abdominal Pain DISEASE at 6 [**5-2**] wks Gestation w/ Known R Ectopic
Pregnancy

Major Surgical or Invasive Procedure:
1) s/p Exploratory laparotomy lysis of adhesions right
salpingo-oophorectomy for ruptured ectopic pregnancy DISEASE
2) CT Angiogram ([**2107-7-21**]) revealing Nonocclusive pulmonary
embolus at the right main pulmonary artery bifurcation.
3) s/p Heparin tx (coupled w/ Coumadin) for tx of pulmonary
embolus


History of Present Illness:
HPI:36yo G3P2002 at 6 6/7wk known ectopic pregnancy represents
to ED w/ increasing intermittent sharp stabbing pain DISEASE in lower
abd starting last night. No radiation of pain DISEASE nothing makes
pain DISEASE
less or worse. Pt denies f/c n/v cp/sob dysuria/hematuria
VB. Pt states the her pain DISEASE was the worst at her initial
presentation on [**2107-7-10**]. Pt was originally xfered from Good
[**Hospital 5159**] Hospital w/ Admission Date: [**2139-10-17**] Discharge Date: [**2139-10-24**]

Date of Birth: [**2087-5-17**] Sex: F

Service: NEUROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
increased [**First Name3 (LF) 862**]

Major Surgical or Invasive Procedure:
lumbar puncture


History of Present Illness:
The pt is a year-old woman with a PMH s/f MS [**First Name (Titles) **] [**Last Name (Titles) 862**] D/O
including a history of status epilepticus DISEASE who presented to
[**Hospital6 5168**] on the evening of [**2139-10-16**] with chief
complaint DISEASE of found unresponsive. History obtained from sister
and from OSH records. The patient was at home and had a fall
which was not unusual. She seemed fine after the fall. She was
found unresponsive at 8:30pm and brought to the OSH. She was
noted to have seizures DISEASE at the OSH by the sister. She was also
noted to be Febrile DISEASE to 101. She had an elevated white count.
[**Date Range **] was managed with ativan (unknown how much)and
phosphenytoin 1000mg x1. An EEG on [**2139-10-17**] showed rare Left
temporal sharps but no seizures DISEASE . The fever DISEASE workup included
UA/UCx BCx chest x-ray non contrast head CT and an LP. None
of these was revealing. The patient was felt to be in a
protracted post-ictal state. A decision was made to transfer
the
patient to the [**Hospital1 18**] for further management. The patient was
put
on a propofol gtt given fentanyl and intubated for airway
protection given the concern that she might seize en route.


Past Medical History:
-Complex partial seizures DISEASE ( staring spells DISEASE and arm extension).
She
had status 10 yrs ago
-Demyelinating disease by MRI and oligoclonal bands on LP in
[**2119**].
-Depression and h/o SI
-Restless legs
-h/o mumps


Social History:
Patient lives with her eldest sister and her 82 year old mother
in [**Name (NI) 5169**] MA where she was born. She is one of six children
having 4 sisters and 1 brother. She describes her family as
being extremely close and supportive of her. She is very close
to her mother and is upset about being away from her during this
hospitalization. She is unemployed at this time due to physical
and cognitive limitations related to her disease. She worked as
a horticulturist doing research in [**State 4565**] and [**State 5170**] in
the past. She is divorced but remains on good terms with her
former husband who lives in CA. She has no children. She has
no history of IV drug use tobacco use or alcohol consumption.


Family History:
Father died of a myocardial infarction DISEASE . Mother is alive and at
82 years of age is in good health. One sister is 42 and also
suffers from a demyelinating disease DISEASE (suspected multiple
sclerosis) which has affected her cognition more than her motor
and sensory systems. This sister has responded well to
Solumedrol infusions and Rebif in the past with resolved speech
and swallowing problems. [**Name (NI) **] had one paternal uncle with
suspected multiple sclerosis DISEASE (diagnosed at age 27 died at 42)
another paternal uncle with paranoid schizophrenia DISEASE another
paternal uncle who died of stroke DISEASE in his 40Admission Date: [**2119-4-23**] Discharge Date: [**2119-4-25**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
STEMI s/p stenting of LAD

Major Surgical or Invasive Procedure:
Cardiac catheterization s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 5175**]

History of Present Illness:
Pt is a 89 yo male with CAD s/p cath [**5-/2107**] (90% stenosis LAD DISEASE s/p
atherectomy) dementia CHF DM DISEASE CRI presents to OSH with
tachypnea DISEASE found to have an STEMI and transferred to [**Hospital1 18**] for
cath. Pt presented to an OSH with SOB from his nursing home. He
had received 20 mg IV lasix prior to arrival at OSH per report.
Pt told OSH ED he had been Admission Date: [**2123-2-2**] Discharge Date: [**2123-2-4**]

Date of Birth: [**2067-12-29**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Vague diffuse abdominal discomfort

Major Surgical or Invasive Procedure:
none

History of Present Illness:
55 yo M with h/o chronic EtOH abuse HTN DISEASE Unit No: [**Numeric Identifier 5181**]
Admission Date: [**2139-6-6**]
Discharge Date: [**2139-6-13**]
Date of Birth: [**2069-9-23**]
Sex: F
Service: [**Last Name (un) **]


HISTORY OF PRESENT ILLNESS: The patient is a 69 year old
woman with history of alcoholic hepatitis DISEASE and GERD DISEASE who
presented with sudden onset of abdominal pain DISEASE mostly
epigastric accompanied by some nausea DISEASE and vomiting chills DISEASE
no fevers DISEASE . Last bowel movement DISEASE was the day prior. She was
passing gas. No chest pain DISEASE no shortness of breath DISEASE . No
melena DISEASE .

PAST MEDICAL HISTORY:
1. Alcoholic hepatitis DISEASE .
2. Hypertension DISEASE .
3. Gastroesophageal reflux disorder DISEASE .
4. Hypercholesterolemia DISEASE .
5. Anxiety DISEASE .
6. History of ventral hernia DISEASE repair.


ALLERGIES: Sulfa.

MEDICATIONS:
1. Atenolol 100 mg daily.
2. Hydrochlorothiazide 25 mg a day.
3. Multivitamin.
4. Prilosec 40 mg a day.
5. Folic acid 1 mg a day.
6. Protonix 40 mg a day.


PHYSICAL EXAMINATION: Pleasant cooperative in mild
distress. Regular rate and rhythm. Clear to auscultation
bilaterally. Abdomen is soft tender to palpation ino the
epigastric area. Rectal exam - guaiac negative no masses.

Labs include white blood cell count of 17 hematocrit of 44
BUN of 7 creatinine of 0.9. AST is 106 ALT 419 alkaline
phosphatase 147 total bilirubin 4.4. Amylase 850 lipase
3234. LDH 408.

STUDIES: CT of the abdomen showed pancreatitis DISEASE with regions
of relative hypo enhancement in the pancreas a distended
gallbladder with stone and distended cystic duct. No
intrahepatic ductal DISEASE dilation.

HOSPITAL COURSE: The patient was admitted to the ICU and was
treated with fluid resuscitation. NPO. Gastroenterology
consultation was obtained. By the next day her enzymes were
improved. The ERCP was held in consideration that the
patient had probably already passed the stone and was now
improving. Her abdominal examination and her labs continued
to improve until [**2139-6-8**] when already on the floor the
patient started complaining of increased abdominal pain DISEASE . The
abdomen showed some distension and the patient's hematocrit
dropped down from 31 to requiring blood transfusion. She
underwent emergent CT scan which showed pseudoaneurysm DISEASE in
adjacent to an SMA DISEASE . The patient underwent angio which
revealed a pseudoaneurysm DISEASE which was coming off from branches
from the SMA DISEASE as well as having a feeder from PDA. They were
able to embolize this pseudoaneurysm DISEASE as well as embolize the
feeder from SMA DISEASE but not from the PDA.

The patient returned to the ICU where her blood pressure was
initially controlled with nitroglycerin drip. Over the next
couple of days the patient's condition has improved. Her
hematocrit remains stable. It was not requiring any
transfusion. Her abdomen although still mildly distended
was soft. She was passing gas and having bowel movements DISEASE . Her
diet was advanced initially to clears and the patient went
to a regular diet which she tolerated well. She started to
ambulate initially with help then on her own. She was
transferred to the floor. The vascular service was consulted.
Their CT was obtained on [**2139-6-8**] which showed no
changes in the pseudoaneurysm DISEASE with hematocrits remaining
stable. The patient was otherwise doing fine. The feeling was
that the patient does not need any procedures at this point.

On [**2139-5-13**] the patient is afebrile. Vital signs are
stable. The abdomen is soft non distended. Tolerating a
regular diet and ambulating without help. No concerns.

CONDITION ON DISCHARGE: Good.

DISPOSITION: The patient is discharged home. The patient
will follow up with Dr. [**Last Name (STitle) 5182**] in 2 weeks for discussing
cholecystectomy at a later date. The patient will also follow
up with Dr. [**Last Name (STitle) **] next week.

DISCHARGE MEDICATIONS:
1. Tylenol 1-2 tabs p.o. every 4-6 hours p.r.n. pain DISEASE .
2. Ativan 1 mg p.o. at bedtime p.r.n..
3. Protonix 40 mg p.o. daily.
4. Lopressor 75 mg p.o. daily.


DISCHARGE DIAGNOSES:
1. Gallstone pancreatitis DISEASE .
2. Hypertension DISEASE .
3. Gastroesophageal reflux disorder DISEASE .
4. Alcoholic hepatitis DISEASE .
5. Hypercholesterolemia DISEASE .
6. Anxiety DISEASE .
7. SMA pseudoaneurysm DISEASE status post bleeding DISEASE and embolization.




[**Name6 (MD) 5183**] [**Last Name (NamePattern4) 5184**] [**MD Number(1) 5185**]

Dictated By:[**Doctor Last Name 5186**]
MEDQUIST36
D: [**2139-6-13**] 12:11:22
T: [**2139-6-13**] 12:51:11
Job#: [**Job Number 5187**]



Admission Date: [**2144-6-9**] Discharge Date: [**2144-6-13**]

Date of Birth: [**2087-3-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Suicide DISEASE Attmpt/Overdose

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
57 year-old female with depression DISEASE prior suicidal attempts
diabetes mellitus type II DISEASE admitted with suicide attempt. She
reports feeling more depressed DISEASE than baseline recently. She tried
to relieve pain/stress with left arm laceration few days ago and
suicide attempt by trying to crash her car yesterday. This
morning she took methadone 120mg PO (from a friend) trazodone
x4 tablets gabapentin 300mg PO x 15 tablets. She does not
recall events following ingestionAdmission Date: [**2143-11-22**] Discharge Date: [**2143-11-25**]

Date of Birth: [**2075-10-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Reason for ICU admission: ROMI coffee ground emesis DISEASE

Major Surgical or Invasive Procedure:
endoscopy

History of Present Illness:
HPI:
68 y.o. man with HTN DISEASE presented to PCP for routine visit on day
of admission c/o 2 months of worsening DOE and chest pressure
with exertion. He reports having a stress test 1 year ago which
was stopped after 3 minutes for hypertension DISEASE (SBP in the 230s).
He had no symptoms and no ST wave changes. In addition he
complains of severe heartburn DISEASE (different than his chest
pressure) intermittently every few days x 3 months along with
violent coughing fits DISEASE which cause him to vomit DISEASE dark brown
liquid. He denies frank blood in his emesis DISEASE . The heartburn DISEASE is
worse at night with lying flat. He denies NSAID use but does
admit to drinking at least [**2-9**] drinks of burbon daily.
.
He was referred to the ED for concern of ACS DISEASE . In the ED he was
afebrile HR 70s BP 116/73m RR 16 and 97% RA DISEASE . Hct was 41. His
trop was negative but ECG showed TWI in V1-V3 which were new. He
was given ASA 325 Lopressor and started on nitroglycerin and
heparin gtt. Became hypotensive DISEASE with nitro to SBP 80s BP
responded to 2L NS. He then started to vomit DISEASE brown colored
guiac positive emesis DISEASE . The heparin and nitro drips were stopped.
He was given IV protonix and Reglan. He was admitted to MICU for
further monitoring/ROMI.
.
ROS: Denies fever chills DISEASE . No h/o blood clot DISEASE or recent travel.
.


Past Medical History:

PMH:
HTN DISEASE
ETOH abuse
h/o perianal abscess DISEASE
CKD DISEASE baseline Cr 1.3-1.4
Glaucoma DISEASE
.


Social History:

Social hx: Lives with his partner (male). Retired budjet analyst
for park service. Has history of alchoholism quit for 20 yrs
then starting drinking again when he retired but much less.
Drinks 2-3 glasses burbon daily more when with friends. Starts
drinking around 5pm. Former smoker Admission Date: [**2120-11-23**] [**Month/Day/Year **] Date: [**2120-11-26**]

Date of Birth: [**2067-8-13**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
weakness

Major Surgical or Invasive Procedure:
none


History of Present Illness:
53 M with CAD ischemic CM DISEASE with depressed DISEASE systolic EF (20%)
diabetes DISEASE and h/o PE on anticoagulation who presented to ED with
LE weakness DISEASE and feeling unwell where he was found to be in ARF DISEASE
complicated by hyperkalemia DISEASE . States that he started to feel
unwell a few days ago. Has been suffering with frequent loose
bowel movements DISEASE a day during the past 4 daysAdmission Date: [**2151-11-8**] Discharge Date: [**2151-11-10**]

Date of Birth: [**2085-10-20**] Sex: M

Service: UROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
BPH

Major Surgical or Invasive Procedure:
TURP [**2151-11-8**]


History of Present Illness:
The patient is a 66-year-old male who underwent 2 procedures at
an outside hospital for treatment of BPH and now presents with
recurrent symptoms.


Past Medical History:
BPH arthritis DISEASE GERD gastric ulcers depression anxiety DISEASE

Social History:
He smokes [**11-24**] pack per day and does not drink alcohol.

Family History:
Non-contributory

Physical Exam:
On Discharge:
VS: Temp 97.7 HR 72 BP 102/60 RR 18 O2 sat 95% on room air
Gen: NAD alert and oriented
CV: RRR
Pulm: clear bilaterally
Abd: soft nontender nondistended
GU: foley with light pink urine

Pertinent Results:
Post-op CBC:
[**2151-11-8**] 02:48PM BLOOD WBC-7.6 RBC-4.99 Hgb-15.7 Hct-45.9 MCV-92
MCH-31.5 MCHC-34.2 RDW-13.2 Plt Ct-182

Work up for altered mental status:
[**2151-11-9**] 05:23PM BLOOD WBC-7.6 RBC-4.17* Hgb-12.9* Hct-37.9*
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.7 Plt Ct-139*
[**2151-11-9**] 05:23PM BLOOD Neuts-83.2* Lymphs-9.7* Monos-4.9 Eos-2.1
Baso-0
[**2151-11-9**] 05:23PM BLOOD PT-14.0* PTT-29.1 INR(PT)-1.2*
[**2151-11-9**] 05:23PM BLOOD Glucose-100 UreaN-13 Creat-0.8 DISEASE Na-144
K-3.5 Cl-115* HCO3-22 AnGap-11
[**2151-11-9**] 05:23PM BLOOD ALT-8 AST-13 LD(LDH)-116 AlkPhos-48
Amylase-30 TotBili-0.7
[**2151-11-9**] 05:23PM BLOOD Lipase-15
[**2151-11-9**] 12:01PM BLOOD CK-MB-4 cTropnT-Admission Date: [**2146-3-29**] Discharge Date: [**2146-4-6**]

Date of Birth: [**2071-5-3**] Sex: F

Service: GEN [**Doctor First Name 147**]

HISTORY OF PRESENT ILLNESS: [**Known firstname 5199**] [**Known lastname 2405**] was a 74 year
old female with a history of diverticulitis DISEASE who was in her
usual state of health until the [**10-28**] when she
passed three bloody bowel movements DISEASE . She also experienced
left lower quadrant pain DISEASE and a gush of bright red blood per
rectum which was recorded twice more with resulting
symptomatology DISEASE between episodes. She was admitted by her
primary care physician to the hospital after having a drop in
her hematocrit of 5 points from 34.8 to 29 at an outside
hospital in 24 hours.

PAST MEDICAL HISTORY:
1. Parathyroidectomy in [**2116**].
2. Status post hysterectomy in [**2110**].
3. Nephrolithiasis.
4. History of diverticulosis DISEASE .
5. History of iron deficiency anemia.
6. Glaucoma.
7. Hiatal hernia DISEASE .
8. Recurrent H. pylori which has just been treated.
9. Anal-rectal fistula DISEASE .
10. Arthritis DISEASE .

MEDICATIONS ON TRANSFER:
1. Zestril 40 mg p.o. q. day.
2. Zantac 300 mg p.o. twice a day.
3. Detrol CA 1 mg p.o. q. day.
4. Xalatan one gtt q. h.s.
5. FESO4 325 mg twice a day.
6. Cosopt one drop o.u. twice a day.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: The patient is married with no tobacco or
ethanol use.

FAMILY HISTORY: Notable for colon cancer DISEASE .

PHYSICAL EXAMINATION: On examination the patient was
afebrile with stable vital signs. Heart rate of 96Admission Date: [**2166-2-19**] Discharge Date: [**2166-2-26**]

Date of Birth: [**2092-12-30**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
IodineAdmission Date: [**2166-4-1**] Discharge Date: [**2166-4-7**]

Date of Birth: [**2092-12-30**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
IodineAdmission Date: [**2182-9-16**] Discharge Date: [**2182-9-20**]

Date of Birth: [**2107-2-27**] Sex: M

Service:

NOTE - An addendum will be dictated when the patient is
discharged.

HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
male with a past medical history significant for coronary
artery disease diabetes DISEASE and chronic renal insufficiency DISEASE
admitted to Coronary Care Unit following cardiac
catheterization for ventilatory support and Intensive Care
Unit monitoring. The patient originally presented to an
outside hospital the morning of admission complaining of
chest pain DISEASE and symptoms of congestive heart failure DISEASE . An
electrocardiogram showed a new left bundle branch block DISEASE . He
was then transferred to [**Hospital6 256**]
for emergent cardiac catheterization. The patient went
immediately to the Catheterization Laboratory upon arrival.
Catheterization showed three vessel coronary artery disease DISEASE
patent graft left internal mammary artery to the left
anterior descending patent saphenous vein graft to the
posterior descending artery and patent saphenous vein graft
to obtuse marginal 1. It was significant for increased right
and left filling pressures. Angioplasty was then performed
on the aortoiliac bypass graft left circumflex coronary
artery with failed angioplasty of obtuse marginal 1. The
patient developed significant respiratory distress DISEASE following
catheterization and was ventilated for ventilatory support
with transfer to the Coronary Care Unit on a ventilator.

PAST MEDICAL HISTORY: Coronary artery disease DISEASE status post
coronary artery bypass graft redo three vessels in [**2159**]
four vessels in [**2170**] diabetes mellitus DISEASE times 13 years
chronic renal insufficiency DISEASE with baseline creatinine 2.3
prostate cancer DISEASE diagnosed in [**2171**] refractory to hormone
therapy followed by Dr. [**Last Name (STitle) **] gout depression anemia DISEASE
congestive heart failure DISEASE with unknown ejection fraction.

SOCIAL HISTORY: History of tobacco use 30 pack years quit
in [**2158**] occasional alcohol.

HOME MEDICATIONS:
1. Calcitriol .25 mcg q. day
2. Calcium acetate 657 mg t.i.d.
3. Docusate 100 mg b.i.d.
4. Epogen 10000 units subcutaneous q. Thursday
5. Felodipine 5 mg q. day
6. Iron 325 mg t.i.d.
7. Fluoxetine 20 mg q. day
8. Glipizide 5 mg q. AM
9. Hydralazine 40 mg b.i.d.
10. Hydroxyzine 25 mg b.i.d.
11. Metoprolol 25 mg t.i.d.
12. Omeprazole 40 mg q. day
13. Senna two tablets b.i.d.
14. Simvastatin 20 mg q. day
15. Allopurinol 50 mg q. day
16. Isosorbide mononitrate 60 mg q. day
17. Lasix 60 mg b.i.d.

PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature
96 heartrate 60 blood pressure 179/57 oxygen saturation
100% on 30% FIO2 weight 108 kg. General: Elderly male in
no acute distress. Head eyes ears nose and throat pupils
equal round and reactive to light and accommodation.
Oropharynx clear. Neck supple. No lymphadenopathy DISEASE . Chest
clear to auscultation anteriorly no wheezes. Heart regular
rhythm II/VI systolic murmur DISEASE at the lower left sternal
border with no radiation. Abdomen soft nontender
nondistended positive bowel sounds. Extremities 1Admission Date: [**2182-9-16**] Discharge Date: [**2182-9-29**]

Date of Birth: [**2107-2-27**] Sex: M

Service: CCU

ADDENDUM: The current summary will cover hospital stay from
[**2182-9-20**] through [**2182-9-29**].

1. GASTROINTESTINAL BLEED: The patient developed
progressive throat and esophageal pain DISEASE and had an episode of
hematemesis DISEASE in which he vomited approximately 500 cc of
blood. GI was consulted. The patient had an EGD which
showed esophagitis DISEASE consistent with likely ischemic changes.
The patient was intubated for the EGD and transferred to the
ICU for closer monitoring. He was started on a Pantoprazole
drip. Following several days of the drip he was transferred
over to p.o. Pantoprazole and his diet was slowly advanced.
He did not have any further episodes of hematemesis DISEASE and his
throat discomfort resolved.

2. RENAL FAILURE: The patient was admitted with baseline
chronic renal insufficiency DISEASE and symptoms of uremia DISEASE over the
previous three months. During the hospitalization he had an
acute bump in his creatinine thought to be ATN DISEASE from
catheterization dye load. Renal consulted and the patient
was started on dialysis on [**2182-9-24**]. He underwent
several hemodialysis sessions to remove excess fluid and then
was started on a regimen of hemodialysis three times each
week. The patient tolerated dialysis well.

3. ACUTE CORONARY SYNDROME: The patient had a non-ST DISEASE
elevation MI on [**2182-9-21**]. Given his acute GI
bleed DISEASE he was not a candidate for anticoagulation and instead
was managed medically. He was established on a regimen of
Carvedilol Captopril hydralazine and Isordil and was also
started on aspirin. The plan is to start the patient on
Plavix when he is further out from his GI bleed DISEASE . His cardiac
medications were titrated up as tolerated throughout his
hospitalization.

4. INFECTIOUS DISEASE: The patient was treated for C.
difficile colitis DISEASE with a ten day regimen of Flagyl. He also
developed an Enterococcus UTI DISEASE and was successfully treated
with Levaquin.

CONDITION ON DISCHARGE: Stable.

DISCHARGE STATUS: The patient was discharged to
rehabilitation.

DISCHARGE DIAGNOSIS:
1. Non-ST elevation myocardial infarction DISEASE .
2. Cardiac catheterization.
3. Chronic renal insufficiency DISEASE with acute renal failure DISEASE
requiring hemodialysis.
4. Clostridium difficile colitis DISEASE .
5. Urinary tract infection.
6. ischemic esophagitis.

DISCHARGE MEDICATIONS:
1. Docusate 100 mg b.i.d.
2. Fluoxetine 20 mg q.d.
3. Hydroxyzine 25 mg b.i.d.
4. Simvastatin 20 mg q.d.
5. Isosorbide dinitrate 20 mg t.i.d.
6. Aspirin 81 mg q.d.
7. Viscous lidocaine 2% 20 ml t.i.d. p.r.n.
8. Pantoprazole 40 mg p.o. q. 12 hours.
9. Calcium acetate 1334 mg p.o. t.i.d. with meals.
10. Carvedilol 50 mg p.o. b.i.d.
11. Sliding scale insulin.
12. Lisinopril 20 mg p.o. q.d.
13. Metoclopramide 5 mg IV q. eight hours p.r.n.
14. Metronidazole 500 mg t.i.d. times one week.

FOLLOW-UP PLANS: The patient is to follow-up with primary
care doctor in one week. Follow-up with GI in two weeks for
repeat EGD.




[**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 5214**]

Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36

D: [**2182-9-29**] 01:48
T: [**2182-9-29**] 14:20
JOB#: [**Job Number 5215**]
Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]

Date of Birth: [**2086-1-10**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV
HCV recent septic arthritis DISEASE on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis DISEASE .
Last night at 3AM patient reports having L weakness DISEASE when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits but did not want to go to the ED because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning patient was
found to have L hemiplegia DISEASE by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage DISEASE on
CT-scan. At OSH patient was normotensive afebrile. He was
given
Ativan 2 mg per unclear reason possibly anxiety DISEASE as patient
denies any convulsions DISEASE . The patient was alert and oriented
during
ambulance ride but became more drowsy unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all which is stable from onset at 3am.

ROS:
Positive for chills sweats chronic numbness DISEASE of toes R knee
pain DISEASE
Negative fevers headache diplopia vision loss tingling loss DISEASE
bowel/bladder control chest pain DISEASE SOB N/V.

Past Medical History:
1. HIV on Abacavir Truvada and Raltegravir. Diagnosed [**2125**] he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis DISEASE s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.

Social History:
Living at home with his father denies current
cig smoking or alcohol in 23 years but prior history of heroin
use.

Family History:
knee surgery in his father


Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient Lying in bed looks drowsy but
arousable
HEENT: no jaundice DISEASE no nuchal rigidity DISEASE OP clear no carotid
bruits DISEASE
Lung: clear no crackles no wheezing DISEASE
Heart: Systolic murmur at USB
Ab: soft NT/ND DISEASE
Ext: R knee with sutures in place warm to touch compared to
left
side no erythema DISEASE or drainage. L toes bandaged.

Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14Admission Date: [**2176-11-1**] Discharge Date: [**2176-11-5**]

Date of Birth: Sex: M

Service:

CHIEF COMPLAINT: Respiratory failure DISEASE .

HISTORY OF PRESENT ILLNESS: This is a 75 year old man with
history of advanced dementia DISEASE ( Alzheimer's type DISEASE ) and type 2
diabetes mellitus DISEASE presenting to the Emergency Department
with fever cough hypoxemia DISEASE . The patient was noted by
caregivers to be more lethargic than usual and with nasal
congestion on the night prior to admission. On the day of
admission the patient was more lethargic Admission Date: [**2186-4-3**] Discharge Date: [**2186-4-17**]

Date of Birth: [**2130-1-17**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Keflex

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic stenosis DISEASE

Major Surgical or Invasive Procedure:
[**2186-4-4**]
Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**] Epic Supra Porcine)

left heart catheterization coronary angiogram
right leg anterior compartment fasciotomy [**2186-4-10**]
closure faciotomy [**2186-4-13**]


History of Present Illness:
This 65 year old gentleman has a history of a bicuspid aortic
valve
associated aortic stenosis DISEASE and history of past aortic valve
endocarditis DISEASE . From a cardiac perspective he reports feeling
well. He shortness of breath palpitations dizziness DISEASE
lightheadedness PND orthopnea DISEASE or lower extremity edema DISEASE . He
does note some mild left chest heaviness DISEASE with exertion.
Although he does not do any regular exercise his activities of
daily living are without limitations. His most recent
echocardiogram early this [**Month (only) 956**] showed severe aortic stenosis DISEASE
with increased gradients and mild left ventricular hypertrophy DISEASE .
Given the severity and progression of his disease he has been
referred to Dr. [**Last Name (STitle) **] for surgical management.


Past Medical History:
Aortic Stenosis DISEASE
Bicuspid Aortic Valve
History of Endocarditis DISEASE
HIV Positive(CD4 576 VL 104 - [**10/2185**])
Chronic Hepatitis C DISEASE - s/p Interferon treatment
Hepatitis A DISEASE & B
Dyslipidemia DISEASE
Hypertension DISEASE
Cervical Radiculopathy
Peripheral Neuropathy DISEASE
History of Shingles
History of Anemia DISEASE
History of Iritis
History of Colonic Polyps DISEASE
- s/p Excision of left arm lipoma [**2184-8-22**]
- s/p I and D of left arm abscess [**2185-11-22**]


Social History:
Lives with: Husband
Contact: Phone #
Occupation: Works as a pharmacy technician
Cigarettes: Smoked DISEASE no [X] yes [] last cigarette Admission Date: [**2174-2-12**] Discharge Date: [**2174-2-14**]

Date of Birth: [**2122-4-28**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
51 yo M with h/o asthma DISEASE and right lung volume loss DISEASE of unclear
etiology (Admission Date: [**2196-1-29**] Discharge Date: [**2196-2-3**]

Date of Birth: [**2161-4-2**] Sex: M

Service: [**Company 191**]

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: The patient is a 34 year old man
with history of obstructive sleep apnea DISEASE and hypertension DISEASE who
presented with sudden onset coughing fit and syncope DISEASE and was
found to have bilateral massive pulmonary embolism DISEASE by CT
angiogram. The patient had noted some shortness of breath DISEASE
and pallor DISEASE with exercise starting in [**2195-4-2**]. During the
summer the patient noticed that he was short of breath after
climbing stairs.

In [**Month (only) **] the patient was diagnosed with question of lung
disease and given Albuterol. The patient's dyspnea DISEASE
progressed and he was started on Pulmicort with some response
on pulmonary function tests. A few days before presentation
the patient called his doctor [**First Name (Titles) 1023**] [**Last Name (Titles) 2875**] the patient with
a Prednisone burst treatment without success. The patient was
at home and dyspneic with minimal activity. The patient had
a chest CT on [**2196-1-29**]. It was noncontrast which was read as
normal.

The day before presentation the patient had a coughing fit
with witnessed syncope DISEASE . The patient denies any hemoptysis DISEASE .
He admitted to fifteen pound weight loss DISEASE over the last few
months. The patient had been on a 24 hour nonstop trip to
[**State 108**] since [**Month (only) **]. The patient denied any family
history of clots or personal history of clots. No recent
trauma DISEASE and no recent surgery.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE .
2. Obstructive sleep apnea DISEASE on CPAP.
3. Tonsillectomy.
4. Question of asthma DISEASE .
5. History of echocardiogram that revealed mild decreased
left ventricular function.
6. History of dyspnea DISEASE on exertion since [**2195-4-2**].

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS ON ADMISSION:
1. Univasc.
2. Prilosec.
3. Prednisone.
4. Multivitamin.

SOCIAL HISTORY: The patient works as a computer networker.
He is married with three children. The patient denies any
tobacco or alcohol use.

FAMILY HISTORY: Significant for rheumatoid arthritis DISEASE and
leukemia DISEASE .

PHYSICAL EXAMINATION: The patient had a blood pressure of
115/70 with a pulse of 118. Respiratory rate was 20 with
oxygen saturation of 100% on two liters. Generally the
patient was a fairly ill appearing man in no apparent
distress. Head eyes ears nose and throat examination
revealed extraocular movements DISEASE intact. The pupils are equal
round and reactive to light and accommodation. On neck
examination jugular venous distention DISEASE was approximately six
centimeters of water. On cardiac examination the patient
was tachycardic with normal S1 and S2 and a III/VI blowing
systolic murmur at the left upper sternal border and left
lower sternal border. There were no lifts or heaves DISEASE
appreciated. Pulmonary examination revealed lungs that were
clear to auscultation bilaterally. Abdominal examination
revealed the belly to be soft nontender nondistended with
no hepatosplenomegaly DISEASE . Rectal examination was negative.
Extremity examination revealed no edema DISEASE although there were
decreased pulses bilaterally.

LABORATORY DATA: The patient had a white blood cell count of
16.0 with a hematocrit of 44.5. The patient had a blood urea
nitrogen of 18 and creatinine of 1.0. The patient's INR was
1.2. The patient had initial CK of 134 CK MB of 7.0 and
troponin of less than 0.3.

Chest x-ray was read as normal. Chest CT angiogram revealed
bilateral pulmonary emboli that were extensive but without
saddle emboli. Lower extremity ultrasound revealed left
distal superficial femoral to popliteal vein clot.

HOSPITAL COURSE: The patient is a 34 year old with a history
of obstructive sleep apnea DISEASE reversible airway disease DISEASE on
pulmonary function tests and dyspnea DISEASE on exertion for six
months who presented with extensive bilateral pulmonary
emboli.

1. Cardiovascular - The patient with extensive pulmonary
emboli with evidence of right ventricular dilatation and
strain on an echocardiogram. Because of the patient's stable
hemodynamics he did not receive thrombolytics but was rather
started on Heparin infusion after a bolus. Workup of
hypercoagulable states were started in the Intensive Care
Unit where the patient was admitted.

The patient had protein C and S antithrombin III factor [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 5244**] prothrombin gene mutation 202-10 analysis
homocysteine level antiphospholipid DISEASE antibody
anticardiolipin antibody studies sent.

The patient was provided with supplemental oxygen. He was
maintained on therapeutic level Heparin. The patient was
stabilized and eventually transferred to the floor. He was
started on Coumadin 5 mg p.o. for the first day and then this
was increased to Coumadin 7.5 mg p.o. for the next two days.

The patient was monitored on telemetry. The patient had
occasional episodes of ventricular bigeminy DISEASE and premature
ventricular contractions DISEASE but otherwise remained in sinus
rhythm. His homocysteine level returned within normal
limits.
On the day of discharge the patient had a therapeutic INR of
2.6. He was discharged on Coumadin 5 mg p.o. q.d. with INR
followed by his primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 4127**].

2. Hematologic - The patient with decreased hematocrit from
42.0 to 37.0 while in the Intensive Care Unit. He was guaiac
negative and this was thought to be secondary to dilution.
His hematocrit remained stable throughout the rest of the
hospital stay.

3. Pulmonary - The patient with obstructive sleep apnea DISEASE on
CPAP. He was maintained on CPAP throughout the
hospitalization and was gradually weaned off supplemental
oxygen to the point where he was saturating 98% in room air.

4. Gastrointestinal - The patient presented with history of
elevated liver function tests. The patient remained with
elevated liver function tests throughout the hospitalization.
His ALT was 112 on the day of discharge and AST was 62. He
will likely need to have these followed up by his primary
care physician.

CONDITION ON DISCHARGE: Excellent.

DISCHARGE STATUS: The patient was discharged home.

MEDICATIONS ON DISCHARGE:
1. Coumadin 5 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.

The patient was advised to follow-up with his primary care
physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 4127**] in one week. The patient
will have INR checked a location close to him with results
faxed to his primary care physician. [**Name10 (NameIs) **] patient will be
referred to the hypercoagulation DISEASE clinic at [**Hospital1 346**]. He was advised to call to make an
appointment at [**Telephone/Fax (1) 5245**].

DISCHARGE DIAGNOSES:
1. Extensive bilateral pulmonary emboli.
2. Possible hypercoagulable DISEASE state.
3. Mild hypertension DISEASE .
4. Obstructive sleep apnea DISEASE .
5. Question of asthma DISEASE .




[**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 910**]

Dictated By:[**Last Name (NamePattern1) 5246**]

MEDQUIST36

D: [**2196-2-3**] 12:59
T: [**2196-2-9**] 12:55
JOB#: [**Job Number 5247**]

cc:[**Name8 (MD) 5248**]
Admission Date: [**2176-12-11**] Discharge Date: [**2176-12-16**]

Date of Birth: [**2121-12-5**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Lithium / Depakote / Neurontin

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
drug overdose respiratory failure DISEASE

Major Surgical or Invasive Procedure:
placement of right IJ

History of Present Illness:
55yo woman with psychiatric DISEASE history and previous suicidal
ideation DISEASE
presented to ED after being found unresponsive. Likely
overdose DISEASE on ativan seroquel and risperdol. On presentation to
the ED
was unresponsive and unstable [**Company 5249**] 104.8 148 16 88% RA DISEASE . Glc
was 123.
She was intubated and given charcoal as well as dantrolene for
potential
NMSAdmission Date: [**2160-10-8**] Discharge Date: [**2160-10-17**]

Date of Birth: [**2086-8-16**] Sex: M

Service: Neurology
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
right handed man with a history of hypertension DISEASE who
presented to the Emergency Room with acute right sided
weakness. The patient was in his usual state of health when
witnessed by his family at 1:00 p.m. on [**2160-10-8**] when
Emergency Room where his vital signs were stable. He denied
complaints on arrival. He denied chest pain DISEASE and
palpitations DISEASE . According to his daughter he has some chronic
shortness of breath DISEASE .

PAST MEDICAL HISTORY: 1. Well controlled hypertension DISEASE . 2.
Benign prostatic hypertrophy DISEASE . 3. Osteoarthritis. 4.
Low B12.

MEDICATIONS ON ADMISSION: Coreg 6.25 mg p.o.b.i.d. Diovan
160/12.5 mg p.o.q.d. Tylenol #3 p.r.n. B12 i.m.q. month
unclear if patient started this yet Celebrex p.r.n.

SOCIAL HISTORY: The patient is a Russian immigrant he is
English speaking. He is a retired artist. He drinks alcohol
rarely and does not smoke.

ALLERGIES: The patient has no known drug allergies DISEASE .

PHYSICAL EXAMINATION: On physical examination on admission
the patient had a blood pressure of 160/100 respiratory rate
14 pulse 60 and oxygen saturation 98% on three liters nasal
cannula. Neck: No carotid bruits DISEASE . Cardiovascular: Distant
heart sounds no murmur. Abdomen: Soft nontender. Lungs:
Clear to auscultation bilaterally. Neurologic examination:
Alert and oriented speech nonfluent DISEASE with paraphrasic errors
Russian accent but speaking in English following commands
repetition mildly impaired severe anomia DISEASE perseverated with
the word Admission Date: [**2150-12-13**] Discharge Date: [**2150-12-19**]


Service: MEDICINE

Allergies DISEASE :
Opioid Analgesics

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest pain DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
83 yo F with known CAD s/p MI baseline LBBB DISEASE who presented with
chest pain DISEASE back pain DISEASE starting at 10:45 am. Admission Date: [**2110-9-2**] Discharge Date: [**2110-9-5**]


Service: UROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5272**]
Chief Complaint:
hematuria DISEASE

Major Surgical or Invasive Procedure:
S/p cystoscopy clot evacuation of bladder [**2110-9-2**]


History of Present Illness:
Mr. [**Known lastname 349**] is a healthy [**Age over 90 **]yo M with hypertension DISEASE
hyperlipidemia DISEASE and type II diabetes DISEASE who developed the acute
onset of pressure both when needing to urinate and when trying
to hold his urine in on the morning of [**2110-9-1**]. He denies any
fevers chills DISEASE night sweats nausea DISEASE or back pain DISEASE . He states
that he was eventually able to urinate but that it took a lot of
effort. Later that morning he also developed hematuria DISEASE and
clots in his urine. This was not associated with pain DISEASE on
urination DISEASE but he did have the continued sensation of pressure.
He called Dr. [**Last Name (STitle) 770**] who advised him to go the ER for
evaluation. Of note he had undergone a urologic evaluation last
Thursday for a urine cytology which was reported as Admission Date: [**2174-9-28**] Discharge Date: [**2174-10-3**]

Date of Birth: [**2097-4-19**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Pericardial effusion atrial fibrillation DISEASE with RVR.

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
Mr. [**Known lastname 1924**] is a 77-year old male with minimal prior medical care
for over 50 years with no known past medical problems who was
brought to the [**Name (NI) **] this morning by his social worker because he
was noted to have labored DISEASE breathing. He minimizes his symptoms
and reports that he has been feeling Admission Date: [**2105-2-25**] Discharge Date: [**2105-2-28**]


Service: MEDICINE

Allergies DISEASE :
Xanax / Vicodin / darvocet

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Respiratory failure DISEASE

Major Surgical or Invasive Procedure:
Mechanical intubation and ventilation.


History of Present Illness:
87 yof with history of atrial fibrillation DISEASE on coumadin with
recent total shoulder arthroplasty secondary to OA DISEASE who presents
in respiratory failure DISEASE . History is obtained from the son who
reports that he was with her until 8pm tonight at which point
she felt well without complaint DISEASE . Around 11pm he received a call
from her complaining of SOB. He notes that she has had a
non-productive cough DISEASE for the past few days but no shortness of
breath until tonight. She was not complaining of chest pain DISEASE or
any other symptoms. He arrived at her house and reports hearing
a gugurling sound while she breathed. EMS was called and pt's
respiratory distress DISEASE progressed requiring intubation in the
field.
.
Upon arrival to the ED CXR was obtained consistent with
pulmonary edema DISEASE . EKG was vpaced and unable to be interpreted for
ischemia DISEASE . She was sedated with fent/versed/propofol and vent
setting on transfer to the MICU were AC TV: 450 P: 18 peep 13
100% fiO2. Her tox screen positive for benzos and tylenol. INR
was elevated at 5.2. Hct was 33.6 down from 36.8 on [**2104-12-22**]. Pt
triggered for hypotension DISEASE and propfol drip was held and she
received 2L of NS. This was followed by a dose of 40mg IV lasix

.
On arrival to the MICU VS were: T 97.8 BP 175/75 HR 65 O2 100%
on the above settings.
.
Review of systems: Unable to obtain as she is intubated.


Past Medical History:
Atypical chest pain DISEASE
paroxysmal Supraventricular Tachycardia DISEASE ( SVT DISEASE ):
- per review of OMR there was concern that she may have AVNRT

although brief episodes of AFib DISEASE noted on interrogation of PPM
Mobitz Type 2 2nd Degree AV block DISEASE [**9-/2101**] s/p PPM
dCHF mild MR DISEASE
Hypertension DISEASE
Chronic back pain DISEASE
Peptic ulcer disease DISEASE
Anemia DISEASE with baseline Hct 31-34
Glaucoma DISEASE
Osteoporosis DISEASE
Osteoarthritis DISEASE
Rotator cuff tearsAdmission Date: [**2145-11-24**] Discharge Date: [**2145-11-30**]

Date of Birth: [**2085-4-13**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain DISEASE

Major Surgical or Invasive Procedure:
Coronary artery bypass graft x3 (LIMA-Admission Date: [**2106-6-10**] Discharge Date: [**2106-6-17**]

Date of Birth: [**2032-5-3**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Aspirin / Penicillins / Sulfa (Sulfonamides) / Latex / Keflex

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain DISEASE

Major Surgical or Invasive Procedure:
Aortic Valve Replacement (19mm Mosaic Poricine) [**2106-6-10**]

History of Present Illness:
74 y/o female with known Aortic Stenosis who presented to ED
with chest pain DISEASE intermittently x 2 weeks. Repeat Echo revealed
worsening AS. Referred DISEASE for elective valve surgery.

Past Medical History:
Aortic Stenosis Hypertension Hypercholesterolemia DISEASE
Hypothyroidism DISEASE Asthma Peripheral Vascular/Carotid Disease
Meneire's Disease Osteoarthritis DISEASE s/p bilat. cataract DISEASE surgery
s/p hysterectomy s/p bladder suspension s/p hemerrhoidectomy s/p cholecystectomy s/p appendectomy s/p hand DISEASE surgery

Social History:
Patient is married and lives at home. Denies DISEASE any history of
smoking EtOH or recreational drug use.

Family History:
Non contributory

Physical Exam:
VS: Afebrile p-70's BP 126/54
General: NAD WD/WN
HEENT: Sclera nonicteric EOMI PERRL
Neck: Supple -JVD Admission Date: [**2106-6-10**] Discharge Date: [**2106-6-17**]

Date of Birth: [**2032-5-3**] Sex: F

Service: CSU


ADDENDUM: While Ms. [**Known lastname **] did have some changes in her
mental status perioperatively there was no evidence either by
radiographic imaging or physical examination that she
suffered a perioperative stroke DISEASE . Her change in mental status
was most likely related to pain DISEASE medication.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**] [**MD Number(1) 1715**]

Dictated By:[**Last Name (NamePattern1) 5297**]
MEDQUIST36
D: [**2106-7-26**] 07:04:33
T: [**2106-7-26**] 09:00:10
Job#: [**Job Number 5298**]
Admission Date: [**2145-11-30**] Discharge Date: [**2145-12-1**]

Date of Birth: [**2091-4-13**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Afib DISEASE with RVR

Major Surgical or Invasive Procedure:
None

History of Present Illness:
54M with hx of ETOH abuse HCV presented to the ED this evening
intoxicated. Upon arrival the pt was noted to have slurred DISEASE
speech and decreased responsiveness. The patient states that
today he invited a friend over to his house where he shared 1L
of vodka. The pt reports that while drinking he experienced left
sided chest pain DISEASE that led his friend to call EMS for him. The pt
states he drinks heavily [**2-3**]/month. He denies history of
seizure DISEASE loss of urine or stool. No loss of consciousness DISEASE no
known trauma DISEASE . The pt describes his chest pain DISEASE as left sided
[**8-12**] with radiation to the left arm. No known CAD.
Admission Date: [**2192-11-24**] Discharge Date: [**2192-12-7**]

Date of Birth: [**2110-10-24**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Nitroglycerin

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
syncope DISEASE

Major Surgical or Invasive Procedure:
[**2192-11-28**] aortic valve replacement (23 mm CE pericardial)/
coronary artery bypass graft(SVG-RCA)/ ligation left atrial
apppendage/Maze


History of Present Illness:
This 82 year old Russian speaking female with known critical
aortic stenosis DISEASE was admitted after a syncopal DISEASE episode today
while at a museum. She was with her daughter and family friend
she felt slightly dizzy and then had episode of loss of
consciousness where she fell into the arms of the family. There
was no trauma DISEASE or head injury DISEASE . The physician family friend
thought the patient was pulseless DISEASE so she initiated CPR but the
pt regained a pulse and consciousness within Admission Date: [**2180-2-2**] Discharge Date: [**2180-2-5**]

Date of Birth: [**2106-8-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Doctor First Name 1402**]
Chief Complaint:
transfer from cath lab for acute pulmonary edema DISEASE s/p cath

Major Surgical or Invasive Procedure:
Cardiac Catheterization with Drug Eluting Stent Placement.


History of Present Illness:
73 yo male with past medical history significant for CAD s/p
CABG insulin-dependent diabetes mellitus hypertension DISEASE
hypercholesterolemia DISEASE and peripheral vascular disease DISEASE PVD was
admitted to [**Hospital1 18**] from [**Hospital3 3583**] with after having had
[**6-23**] substernal chest pain DISEASE . Patient was initially admitted to
[**Hospital3 3583**] on [**2180-1-30**] with a COPD DISEASE exacerbation and a right
lower lobe pneumonia DISEASE being treated with IV antibiotics
steroids and nebulizer treatment. On [**2180-2-1**] patient
experienced [**6-23**] substernal chest pain DISEASE with associated bilateral
arm numbness DISEASE and troponin I of 11. He initially received
morphine and ativan without relief and then received 5mg IV
metoprolol and IV nitroglycerine with relief. On 12.20 patient
found to have troponin I with 83.41 and was transferred to [**Hospital1 18**]
for cardiac catheterization.
.
At cardiac cath patient found to have the following: 3 vessel
native coronary artery diseaseAdmission Date: [**2181-10-5**] Discharge Date: [**2181-10-13**]

Date of Birth: [**2106-8-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
Mr. [**Known lastname 5314**] is a 75 yo male with h/o CHF DISEASE and CAD s/p CABG who
presented to presented on [**10-4**] to [**Hospital3 3583**] with a
complaint DISEASE of chest pain DISEASE and shortness of breath DISEASE . Patient is
intubated at time of transfer to [**Hospital1 18**] and history was obtained
almost entirely from discharge summary.
.
At time of admission to [**Hospital3 3583**] he described sudden
onset of sharp left-sided chest pain DISEASE with onset at rest. On
arrival to the ED he reported shortness of breat and was found
to have SpO2 84% on room air. He was placed on a nonrebreather
and was subsequently intubated in the ED for respiratory
failure. The patient was treated with lasix and responded with
good UOP and improvement of his respiratory status. ABG
performed 90 minutes after intubation was 7.18/72/86.
.
Mr. [**Known lastname 5314**] was subseqnetly admitted to the CCC at [**Hospital1 3325**] where he was started on standing IV lasix Nitro paste
1Admission Date: [**2127-3-9**] Discharge Date: [**2127-3-14**]

Date of Birth: [**2054-11-23**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered Mental Status hypotension DISEASE

Major Surgical or Invasive Procedure:
CVL placement

History of Present Illness:
Ms. [**Known lastname 5320**] is a 72 y/o female with a history of HCV metastatic
HCC DISEASE that is not amenable to treatment who initially presented
to the ER with altered mental status since last night. Her
daughters say that starting yesterday she was much more sleepy
not wanting to get up they also said that she had been coughing
and having nasal congestion DISEASE . She was not eating or drinking
much only a few small sips of water. This morning she was not
really waking up much so they called 911. A BLS ambulance
arrived and her fingerstick was 27 they attempted to give her
oral glucose while awaiting an ACLS ambulance after the oral
glucose her repeat blood sugar was 17. After the ACLS ambulance
arrived she was given 1 amp of D50 and brought her into the
[**Hospital1 18**] ER.
In the ED initial VS were: 97 83/41 22. She was given 2LNS
but remained hypotensive DISEASE so a right IJ was placed and she was
started on levophed. A bedside ultrasound was done that showed a
small amount of ascites DISEASE a paracentesis was attempted twice but
failed a CXR was concerning for possible pneumonia DISEASE so she was
given vancomycin ceftriaxone and flagyl. Labs were notable for
a WBC of 2.1 with 25bands lactate of 6.7 INR of 2.6 U/A with
19 white cells Cr of 2.5 from a baseline of 1.0. VS on
transfer: 124/97 on 0.03 of levo 77 22 95-100% on RA DISEASE .
.
On arrival to the MICU her initial VS: 98.8 118 124/64 20
94% on 3LNC. Using her daughters to translate she denied any
pain chest pain shortness of breath nausea/vomiting DISEASE or
abdominal pain DISEASE .
.
Review of systems:
(Admission Date: [**2163-10-6**] Discharge Date: [**2163-10-13**]

Date of Birth: [**2086-4-12**] Sex: F

Service: ORTHOPAEDICS

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 64**]
Chief Complaint:
left hip pain DISEASE [**2-14**] protusion failed left THR

Major Surgical or Invasive Procedure:
left revision THR


History of Present Illness:
Patient is a 77F who had a primary left total hip replacement in
[**2152**] by another surgeon that sustained progressive protrusio
early ultimately failing with loss of fixation of the
acetabulum. I brought [**Known firstname 5321**] to surgery a little over a year ago
at which time we felt that her best treatment option
intraoperatively would be allograft packing of the acetabulum
defect and a
hemiarthroplasty head. Also considered at the time was a
Restoration GAP prosthesis. She did well for probably 10 or 12
months and then started developing pain DISEASE and x-rays demonstrated
progressive protrusio with the femoral head at risk for pushing
through the remnant of the acetabulum. We have also seen
insufficiency fractures DISEASE developing on the pubic ramus and in the
posterior wall of the acetabulum. The patient is developing
progressive pain DISEASE unrelenting and sciatic symptoms. She has
been made nonweightbearing a couple
months ago in preparation for the surgery. She understands this
is very much a salvage operation. She is developing progressive
fracturing from osteoporosis DISEASE and there is very little bone stock
remaining. She is really not a candidate
for major allograft pelvic reconstruction as fixation would be
limited. Best treatment course cemented GAP cage and avoidance
of further allograft.


Past Medical History:
history lymphoma in [**2160**] history of ovarian cancer DISEASE splenectomy
[**2160**] for lymphomaAdmission Date: [**2164-5-3**] Discharge Date: [**2164-6-12**]

Date of Birth: [**2086-4-12**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Left leg pain DISEASE & malaise


Major Surgical or Invasive Procedure:
[**2164-5-4**] R-Admission Date: [**2164-6-24**] Discharge Date: [**2164-7-20**]

Date of Birth: [**2086-4-12**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
persistent anemia DISEASE bloody ostomy output leukocytosis DISEASE

Major Surgical or Invasive Procedure:
[**2164-6-28**]: PEG placement
[**2164-7-1**]: Decompression of septic left pelvic hematoma DISEASE
irrigation and debridement via arthrotomy down to the
acetabular space cultures and placement of vacuum sponge.
[**2164-7-1**]: Re-exploration of left thigh bleeding DISEASE .
[**2164-7-5**]: Serial irrigation and debridements of left hipAdmission Date: [**2125-4-29**] Discharge Date: [**2125-5-29**]

Date of Birth: [**2053-11-6**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Vancomycin

Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Rib pain DISEASE

Major Surgical or Invasive Procedure:
Intubation
Stress MIBI


History of Present Illness:
71 y/o F w/ metastatic breast ca w/ bone involvement on
tamoxifen who presents with worsening right rib pain DISEASE .
.
She reports that rib pain DISEASE has been a chronic problem but has
been worse over past one week. The right side is worse but she
also reports left sided rib pain DISEASE and chest wall pain DISEASE . She does
not report any trauma DISEASE or heavy lifting or turning that seemed to
precipitate the pains DISEASE . She was recently started on percocet for
pain DISEASE which did help but she has had to take it around the clock
without full relief.
.
ROS: denies n/v/f/c. no chest pain DISEASE . Admission Date: [**2121-8-20**] Discharge Date: [**2121-8-28**]

Date of Birth: [**2050-2-24**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Morphine / Aspirin / Methocarbamol / Meperidine / Hydrocodone

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
71F with PMH of CHF AAA DISEASE and chronic back pain DISEASE presenting from
Rehab with confusion DISEASE and disorientation DISEASE found to have a TAdmission Date: [**2148-3-2**] Discharge Date: [**2148-3-7**]

Date of Birth: [**2070-10-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension/hypoxia DISEASE

Major Surgical or Invasive Procedure:
Placement of Dobhoff tube
Placement of Arterial line

History of Present Illness:
77 yo M NH resident h/o schizophrenia DISEASE CAD HTN dementia DISEASE p/w
hypoxia DISEASE and FTT from NH. According to the NH records pt had an
episode of desaturation DISEASE to mid 80's on RA DISEASE several days ago. He
came up to 91% on 2L NC. He was also noted to have decreased po
intake eating only with assistance and only preferred foods.
IVF fluids were given. CXR at NH neg UA pos. Started on
levaquin 500 mg po on [**2-29**] also given 1 dose of CTX.
Subsequently ucx came back as Admission Date: [**2194-5-8**] Discharge Date: [**2194-5-14**]


Service: MEDICINE

Allergies DISEASE :
Lisinopril / Nsaids / Nesiritide

Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
* interview conducted with the aid of Ms. [**Known lastname 1862**] daughter
.
History of Present Illness: Ms. [**Known lastname **] is an 86 y/o F with
history of nephrotic DISEASE CRI renal artery stenosis DISEASE and CHF DISEASE who
presented with hypertensive DISEASE emergency and heart failure DISEASE . The
patient reports that she was in her usual state of health until
3 days prior to admission. At that time her BP was 220 systolic
Admission Date: [**2148-3-20**] Discharge Date: [**2148-3-29**]

Date of Birth: [**2070-10-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
CVL placement
Intubation
J-tube placement

History of Present Illness:
Mr. [**Known lastname 5345**] is a 77 year-old male with a history of CAD s/p
CABG HTN schizophrenia DISEASE recent admission for
hypoxia/hypotension with unknown etiology who presents from
rehab with hypoxia DISEASE to 78 on RA DISEASE - 88 on NC. His PCP at [**Name9 (PRE) 5346**] started him on cefepime 1g IV bid for one week starting on
[**3-14**] for a positive UA in setting of elevated white count.
According to her she sent three C diff samples that were
negative and had given him empiric flagyl for three days in the
interim.
.
He was sent to the ER where he was found to be 92-96 on NRB
mask. His BP ranged from 90s-120s. He was intubated for hypoxia DISEASE
(etomidate and succinylcholine given). CXR was performed and he
was given levoflox and ctx x 1. OGT was placed. Thick yellow
sputum was suctioned from his ETT. He recieved 3L NS. Troponin
returned at 0.13 with flat CK and his EKG (Qs in V1-4 but no
change from prior) was faxed to cardiology who did not suspect
acute MI and recommended he be given aspirin only (he was given
ASA 325 mg po x 1). His WBC was 25.6 with 92% PMNs and no bands.
UA was negative. Lactate was 1.7. Electrolytes were normal.
.
Of note he was recently hospitalized [**Date range (1) 5347**] in the ICU after
being admitted for desat to 80s hypotension DISEASE . He was started on
empiric antibiotics at that time for possible aspiration pna
however all culture data and imaging was negative and was
stopped. Imaging of his L ankle decubitus ulcer DISEASE did not show
osteomyelitis DISEASE . He was also worked up for AMS with head CT and
neuro c/s. Neuro felt he may have had a small TIA DISEASE with R sided
weakness DISEASE and transient R sided facial droop. He was continued
on aspirin an increased dose of statin and Plavix. His
neurological symptoms DISEASE had resolved at the time of discharge. He
was fed through an NGT however when he was discharged to his NH
this was pulled and he continued to have poor nutritional
intake which is not ideal especially given his chronic
decubitus ulcers DISEASE (5 of them). He has an appointment for PEG
placement on [**3-22**] for poor nutritional status. Echo during his
last hospitalization showed EF 35% and EKG and CEs were
consistent with likely MI prior to admission (trop 0.14). He was
admitted to the MICU for further care.
.
ROS: Unable to assess given pt sedated intubated

Past Medical History:
Recent hospitalization for hypoxia hypotension DISEASE of unknown
etiology
TIA DISEASE in [**3-5**]
Schizophrenia DISEASE per PCP [**Name Initial (NameIs) 5348**] AAOx1 verbally abusive
Depression DISEASE
HTN DISEASE
Dementia DISEASE
R eye cataract DISEASE
CAD s/p CABG

Social History:
Eats a pureed diet. Mostly bedbound at [**Name Initial (NameIs) 5348**]. Pt has no
family. Has legal guardian [**Name (NI) 3608**] [**Name (NI) 4334**]. Per discussion with
PCP [**Name10 (NameIs) 3608**] is not comfortable making code decision for pt so
there was a court date on [**3-19**] to appoint a guardian ad [**Name2 (NI) 5349**]
for the purposes of making code decision for pt. This person has
yet to be appointed.


Family History:
Non-contributory

Physical Exam:
Vitals: T: 97.9 BP: 116/64 HR: 88 RR: 18-20 O2Sat: 100% on
AC 500*14 RR 16 FiO2 0.5
GEN: opens eyes to name does not withdraw to pain DISEASE sedated
intubated.
HEENT: R eye surgical pupil bilat pupils small L eye sluggish
response.
COR: RRR no M/G/R normal S1 S2
PULM: Lungs CTAB decreased at bases bilat
ABD: Soft NT ND diminished BS no HSM
EXT: No C/C/E 1Admission Date: [**2148-4-8**] Discharge Date: [**2148-4-8**]

Date of Birth: [**2070-10-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
hypoxia DISEASE s/p PEA arrest DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
77 male nursing home resident 2 admissions in past month sent
to the ED from his NH with hypoxia DISEASE and worsening L sided PNA.
He was found to have an O2 sat in the 70's while receiving 100%
oxygen by non-rebreather face mask. He had some ectopy for
which he received 75 mg of amiodraone. He was intubated and his
oxygen saturations remained low in the 60's with PAO2 in the
40's on vent settings of AC 500 x 15 10 peep. His CXR showed
worsened PNA with white out of the L lung and his labs returned
with Admission Date: [**2110-9-15**] Discharge Date: [**2110-10-23**]

Date of Birth: [**2060-1-1**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Ibuprofen

Attending:[**First Name3 (LF) 465**]
Chief Complaint:
lethargy DISEASE

Major Surgical or Invasive Procedure:
intubation x2
colonoscopy
EGD
right femoral line
left sunclavian line
left cordis DISEASE with Swan
arterial line


History of Present Illness:
The pt is a 50yo M with PMHx significant for alcohol abuse DISEASE and
CAD with multiple MI's prior MI [**2105**] with OM stent and PCI at
[**Hospital1 18**] [**2109-4-20**] of the proximal RCA and mid-RCA (both Taxus)
LAD stent at [**Hospital1 112**] in [**2105**]. The patient initially was in the
[**Hospital 5353**] Hospital ED on [**9-8**] with chest pain DISEASE . EKG showed NSR
nonspecific ST-T changes per report. The paitent left AMA before
further w/u was done. He then presented to [**Hospital3 **] via
EMS on [**9-15**] with increase lethergy and jaundice DISEASE for the last
three days. He was transfeed to [**Hospital1 18**] ED for a GIB DISEASE and a HCT of
21. He was transfused before transfer with 1 unit.
.
From the medicine admission note:
Pt states he has never had liver problems DISEASE or h/o jaundice DISEASE but
has taken about 14 tylenol over past week for chronic back pain DISEASE .
Pt reports he was on an alcohol binge while in [**Location (un) 5354**] one
week ago. Around the time he came back he developed chest pain DISEASE
and was seen in the [**Hospital3 **] ED where chest pain DISEASE resolved
with NG and he was discharged. Pt is very unclear about this -
states that he had an MI but was only given SL NG and was
discharged without admission. [**Hospital3 **] was contact[**Name (NI) **] and
they currently have no record of EKGs or other records
indicating that pt was seen one week ago - at last communication
with RN in ED of [**Hospital1 **] it was felt that perphaps visit had not
yet been logged in to computer and will need to contact again
tomorrow. Since that time he developed melena DISEASE and jaundice DISEASE . He
denies dizziness DISEASE or chest pain DISEASE but in the [**Hospital3 **] ED he
was found to have elevated LFTs Hct of 22 received 1u PRBC and
transferred to [**Hospital1 18**]. Here pt refused EGD and NG lavage. In
[**Hospital1 18**] ED received 2u PRBC octreotide and PPIs as well as KCL
for hypokalemia DISEASE N-acetylcysteine for elevated tylenol levels
and antibiotics for bandemia DISEASE . RUQ showed gall baldder sludge DISEASE but
no bilary dilation. He was felt to have no ascites DISEASE and so was
not tapped. After receiving the two units of PRBC he desaturated
to from 96% to 88% on RA DISEASE . Received Lasix for volume overload DISEASE
.
The paitent was then admitted to a medicine team via NF. He
recieved a total of 3 transfusions here and his and his HCT has
only gone up from 22.6 to 25.2. Also he has having multiple
episodes of melana. He went for an EGD today ([**9-16**]) but was not
coorperative despite midazloam 3mg and meperidene 75mg. He also
started to have hallucinations DISEASE on the floor. Therefore he was
tx to the MICU for closer monitoring and intubation for EGD.
.
.
ROS: denies CP SOP abd pain DISEASE . Per wife he always hs wheezing DISEASE
not dx with a lung condition. He has been having increasing
swelling DISEASE in his left lower leg for the past 6 months.

Past Medical History:
-alcohol abuse - pt reports that he drinks 2-3 beers per day
denies DTs. no prior history of liver disease DISEASE
-CAD s/p MI [**2105**] stent LAD [**2107**] stent mid and prox RCA in [**2108**]

- Per wife in [**2082**] the patient had a motorcycle accident and
broke his femur and had compartment syndrome DISEASE leading to a
fasicotomy in the right lower leg. He has had multiple DVT DISEASE 's
since in that leg.
- herniated lumbar disc DISEASE with sciatica DISEASE on chronic pain DISEASE
medications


Social History:
90 tobacco pack yr history lives alone drinks beer and liquor
[**1-24**] drinks per day on diasbilty for the last 10 years
Per the patient's wife: The patient has a h/o a sucide attempt
by cutting his wrists 5 years ago. She dose not know of any
inpatient ETOH detox stays DTs or seizures DISEASE . The patient has
been living alone for the last 6 months becaue she could not
tolerate his drinking. recently he has switched to vodka.

Family History:
multiple MI's

Physical Exam:
T 99.7 P 90 BP: 112/72 RR 20Admission Date: [**2173-9-3**] Discharge Date: [**2173-9-22**]


Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Cold foot

Major Surgical or Invasive Procedure:
Angiography/stent left Superficial Femoral Artery


History of Present Illness:
86 y/o male with a hx of 3V CAD CHF DISEASE - EF 35% chronic afib
DM2 PVD DISEASE s/p bypass L [**Doctor Last Name **]--Admission Date: [**2119-4-13**] Discharge Date: [**2119-4-18**]

Date of Birth: [**2084-2-7**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Latex / Erythromycin Base / Percocet / Vicodin / Sulfa
(Sulfonamides) / Penicillins / Alcohol / Egg

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
35F with 6 months of headaches DISEASE and intermittent dizziness DISEASE who
was found to have a 2.4cm left cerebellar brain mass

Major Surgical or Invasive Procedure:
[**2119-4-13**]:Left suboccipital craniotomy for tumor DISEASE resection with
cranioplasty


History of Present Illness:
35 year old female presents with approximately 6 months of
headaches DISEASE and intermittent dizziness DISEASE . She reports no visual
changes no new gait disturbances no numbness DISEASE or tingling. Her
PCP referred her to Dr. [**Last Name (STitle) **] who ordered an MRI of the brain.
She had this in [**2119-1-10**] and the study revealed a brain
mass in the left cerebellum measuring 2.4 cm at the greatest
diameter. Dr. [**Last Name (STitle) **] then referred her to Dr. [**Last Name (STitle) **] for
neurosurgical
consultation.

Past Medical History:
sarcoidosis DISEASE (affecting liver and kidneys) - dx DISEASE in [**2115**]
multiple ear infections DISEASE s/p multiple surgeries s/p lymph node
biopsy s/p kidney biopsy s/p cyst removal HTN DISEASE (secondary to
sarcoidosis DISEASE in kidneys) hypercholesterolemia DISEASE


Social History:
lives alone works as Nanny part time

Family History:
mother:died from metastatic breast CA maternal
grandmother and [**Name2 (NI) 5358**] aunt both had non-[**Name (NI) 4278**] Lymphoma DISEASE
maternal grandfather had leukemia DISEASE


Physical Exam:
On Discharge:
Neurologically intact. Scalp incision clean dry DISEASE intact. Rash DISEASE
to FA significantly improved with only trace red pigmentation
and non-pruritic.

Pertinent Results:
Labs on Admission:
[**2119-4-13**] 01:59PM BLOOD Hct-34.9*
[**2119-4-14**] 01:26AM BLOOD Plt Ct-311

------------------
IMAGING:
-----------------
NCHCT [**4-13**](post-op): stable with expected post-operative
changes.

MRI Head [**4-14**](post-op): Expected postsurgical changes identified
at the left posterior fossa status post meningioma DISEASE resection as
described. There is no evidence of intracranial hemorrhage DISEASE or
ischemic changes. The previously noted meningioma DISEASE at the left
posterior fossa has been resected with no evidence of residual
mass followup after complete reabsorption of the post-surgical
blood products is recommended


Brief Hospital Course:
Patient presented electively for resection of left posterior
fossa mass on [**2119-4-13**] and underwent left suboccipital craniotomy
for resection of mass with cranioplasty without complications.
Preliminary pathology in the OR showed that the mass was a
menigioma. She was extubated in the OR and transferred to the
ICU post-op. Upon her post-op check she was found to be full
strength with PERRL EOM's intact no drift and no dysmetria.

On POD#1 her examination was stable so she was transferred to
the neurosurgery floor following her routine post-operative MRI.
Her steroids were ordered to taper to off over four days.

She was seen and evaluated by PT and OT who determined that she
was safe to go home without services. The patient developed a
rash DISEASE on the left forearm which was initially thought to be
cellulitis DISEASE or an allergic reaction DISEASE . She was placed on
clindamycin for a couple of days. The rash DISEASE was pruritic DISEASE in
nature and improved greatly with benadryl. Therefore the
Clindamycin was discontinued. The rash DISEASE subsequently improved

The patient continued to have pain DISEASE that was [**6-19**] on [**4-17**] so her
pain DISEASE regimen was adjusted accordingly. She responded well and
was discharged to home in good condition on [**2119-4-18**]. of note
the rash DISEASE to her L FA was very faint and no longer pruritic at
the time of discharge.


Medications on Admission:
CeleXA 20mg'Jolessa 0.15mg/30mcg'Valsartan 160mg' Lorazepam
prn spasmDiazepam 5mgAdmission Date: [**2107-7-10**] Discharge Date: [**2107-7-26**]


Service:

ADMITTING DIAGNOSIS: Status post cardiac arrest DISEASE

HISTORY OF PRESENT ILLNESS: This is an 89 year old woman
with a history of atrial fibrillation DISEASE pulmonary
hypertension gastrointestinal bleed DISEASE with chronic anemia DISEASE
chronic renal insufficiency DISEASE who had been complaining at home
of lower back pain DISEASE . On the morning of admission her daughter
was helping her to the bathroom when the patient collapsed
without breathing without pulse. Daughter and [**Name2 (NI) 802**]
initiated cardiopulmonary resuscitation and Emergency Medical
Services were called. Emergency Medical Services arrived and
placed an automated external defibrillator which determined a
shockable DISEASE rhythm. She received one shock DISEASE of 200 joules which
converted her to a pulseless DISEASE electrical activity rhythm. She
was given Atropine and a second shock DISEASE and went into an atrial
fibrillation DISEASE rhythm with a rapid ventricular response. The
patient was started on Lidocaine drip and was transferred to
the [**Hospital6 256**] Emergency Room.
Total time pulseless DISEASE was approximately 15 minutes. The
patient arrived to the Emergency Room in rapid atrial
fibrillation DISEASE with a blood pressure in the 80s and was started
on intravenous fluids. Initial electrocardiograms showed no
significant ST or T wave changes. Her first CK was 48 her
component was 2.7 her potassium was 2.5. At this time it is
felt likely that she had suffered a primary arrhythmia DISEASE
leading to her arrest. The patient was not taken to the
Catheterization Laboratory but was admitted to the Coronary
Care Unit for further management.

PAST MEDICAL HISTORY: Atrial fibrillation DISEASE for which she is
on Amiodarone. She has a history of a congestive heart
failure with an echocardiogram in [**2107-1-31**] showing
concentric left ventricular hypertrophy with an ejection
fraction of 50%. She had biatrial enlargement DISEASE moderate
mitral regurgitation DISEASE and severe pulmonary hypertension DISEASE . She
also had a history of chronic anemia DISEASE . She has a history of a
gastrointestinal bleed DISEASE in [**2107-3-31**] which was felt to be
due to a gastric arteriovenous malformation DISEASE . She also has
chronic thrombocytopenia DISEASE with a baseline platelet count of
about 80000. She also has chronic renal insufficiency DISEASE . Her
baseline creatinine is approximately 1.4.

MEDICATIONS AT HOME:
1. Aspirin 81 mg q.d.
2. Toprol XL 25 mg q.d.
3. Zestril 40 mg q.d.
4. Prilosec 20 mg q.d.
5. Multivitamin one tablet q.d.
6. Amiodarone 200 mg q. day

SOCIAL HISTORY: She lives with her family she has a
homemaker. She walk with a cane. She does not have a
history of tobacco and she occasionally uses alcohol.

ALLERGIES: No known drug allergies DISEASE .

PHYSICAL EXAMINATION: On admission her vital signs were
temperature of 98.6 heartrate 109 blood pressure 130/78
breathing 24 times per minute. She was vented on assist
control 500 cc by 12 with 60% FIO2 and positive
end-expiratory pressure of 5. Initial examination was an
elderly intubated woman who was sedated. Head eyes ears
nose and throat examination showed her to be normocephalic
atraumatic with bilateral surgical pupils. Neck examination
was supple with no jugulovenous distension appreciated.
There was no lymphadenopathy DISEASE noted. Cardiac examination
showed a right ventricular heave. It was irregularly
irregular with S1 and S2 and S3 murmur. Her chest
examination was clear to auscultation bilaterally. Her
abdomen was soft and distended but nontender. There were
bowel sounds in all four quadrants. She was guaiac positive
from below. Her extremities showed trace peripheral edema DISEASE .
There were 2Admission Date: [**2107-12-17**] Discharge Date: [**2107-12-24**]


Service: MICU

CHIEF COMPLAINT: Hypotension times one day.

HISTORY OF PRESENT ILLNESS: The patient is an 89 year old
African-American female admitted in [**7-1**] after v-fib arrest.
The patient was defibrillated in the field which was
complicated by anoxic encephalopathy DISEASE and the patient has
remained vent dependent with PEG at JMR since. The patient
had a large occiput decub debrided on day prior to admission
and was subsequently noted to have persistent hypotension DISEASE
with IVF at 75 cc per hour and atrial fibrillation DISEASE at a rate
greater than 100. Today labs returned showing white blood
cell count of 50 hematocrit 17 platelets 42 with a systolic
blood pressure in the 80s. Temperature was 98.4 heart rate
76 respiratory rate 19. The patient was started on dopamine
and was not given vanc/ceftaz 1 gm which had been ordered
but not given. The patient was transferred to [**Hospital1 18**] for
further management. In the emergency room blood pressure was
99/49 heart rate 142 temperature 100.6 rectally. The
patient's blood pressure then dropped to 40/palp and heart
rate was 130. EKG at that time showed a-fib with rapid
ventricular rate. The patient was cardioverted into a slower
rate but still with a-fib. The patient's blood pressure
returned to 120/60. The patient was started on
Neo-Synephrine in the emergency room as well. There were
several central line attempts made in the left subclavian
right groin then left groin with success. The patient was
given 2 liters of normal saline and then transferred to the
MICU.

PAST MEDICAL HISTORY: Significant for v-fib arrest DISEASE
complicated by anoxic encephalopathy DISEASE and vent dependent since
[**7-1**]. Seizures status post status epilepticus DISEASE in the past.
Anemia DISEASE . A-fib with CHF DISEASE . Status post PEG. Chronic renal
insufficiency. GI bleed/gastric AVM DISEASE . Severe PHTN DISEASE .
Thrombocytopenia DISEASE .

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS ON TRANSFER: Amiodarone 200 mg p.o. q.day
Neurontin 600 mg t.i.d. Flagyl 500 mg p.o. t.i.d.
omeprazole 20 mg p.o. b.i.d. Colace 100 mg p.o. b.i.d.
captopril 25 mg p.o. t.i.d. Lopressor 12.5 mg p.o. b.i.d.
multivitamin Tylenol Darvocet Klonopin.

SOCIAL HISTORY: The patient previously lived with family.
Now the patient is vent dependent at JMR. No tobacco in the
past. Social ETOH.

PHYSICAL EXAMINATION: The patient was an obese
African-American female trached unresponsive in
decerebrate positioning in no apparent respiratory distress DISEASE .
Vital signs were temperature 98.4 heart rate 70 blood
pressure 115/40. Vent setting AC tidal volume 600
respiratory rate 15 PEEP 5 FiO2 50%. The patient was
sating 100%. HEENT: 4 to 5 cm occiput decub to skull about
8 mm deep. Pupils nonreactive left about 5 mm right
approximately 3 mm fixed. Anicteric. Positive pallor DISEASE .
Neck trached no lymphadenopathy DISEASE JVP not seen secondary to
habitus. Difficult range of motion but not meningitic DISEASE .
Chest symmetrical good air exchange and minimal expiratory
wheezes bilaterally. CV irregularly irregular heart rate
normal S1 S2 no murmurs rubs or gallops. Abdomen:
decreased bowel sounds moderately distended with
reproducible umbilical hernia DISEASE . OB positive. Extremities had
no clubbing cyanosis DISEASE positive 2 to 3Admission Date: [**2118-7-18**] Discharge Date: [**2118-7-27**]

Date of Birth: [**2042-6-28**] Sex: M

Service: CSU DISEASE


CHIEF COMPLAINT: Chest pain DISEASE and back pain DISEASE .

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 76-year-old man
with a history of hypertension hyperlipidemia DISEASE and prior
myocardial infarction DISEASE with a percutaneous transluminal
coronary angioplasty of the right coronary artery in [**2107**] at
the [**Hospital1 69**]. He states that he
has experienced pain DISEASE and tightness DISEASE in his back radiating into
both shoulders starting on [**2118-7-15**]. The patient denies
shortness of breath dizziness diaphoresis DISEASE or nausea DISEASE . The
pain DISEASE lasted for 30 seconds following pushing a wheelbarrow
and resolved with rest. The patient denied any prior
episodes of pain DISEASE or any since [**2107**] following the initial
episode of pain DISEASE .

The patient informs his primary care provider who referred
him to the emergency room. He then presented to [**Hospital3 5363**] where he was ruled out for an myocardial infarction DISEASE
by enzymes and electrocardiograms. The patient also
underwent a negative evaluation for dissecting aortic
aneurysm DISEASE . On [**2118-7-16**] the patient began experiencing
continuing chest pain DISEASE of increasing intensity. He was
treated with nitroglycerin paste and IV Integrelin as well as
Plavix. At that time he ruled in for an NST EMI with a peak
CK of 412 and a troponin of 6.23. Electrocardiograms
progressed to inverted T waves in V5 and V6. The patient is
now transferred to [**Hospital1 69**] for
cardiac catheterization.

PAST MEDICAL HISTORY: Hypertension hyperlipidemia DISEASE IMI in
[**2107**].

PAST SURGICAL HISTORY: Partial thyroidectomy herniorrhaphy
percutaneous transluminal coronary angioplasty of the RCA in
[**2107**] left knee surgery as well as tonsil and adenoid DISEASE
surgery.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS AT HOME:
1. Flomax 0.4 q.d.
2. Aspirin 325 q.d.
3. Lipitor 10 q.d.
4. Naproxen p.r.n. as well as several vitamins and
supplements.
5. Zestoretic with an unknown dose.


MEDICATIONS ON TRANSFER:
1. Captopril 25 t.i.d.
2. Protonix q.d. 40.
3. Nitroglycerin paste 1 inch q. 6 hours.
4. Lopressor 25 b.i.d.
5. Plavix 75 q.d.
6. Lovenox 90 b.i.d.
7. Aspirin 325 q.d.
8. Lipitor 10 q.d.


SOCIAL HISTORY: Married retired accountant with six
children. He denies any tobacco use 2 to 3 alcohol drinks
per week.

FAMILY HISTORY: Father died in his 80's of pacemaker
failure DISEASE also had a myocardial infarction DISEASE in his 70's.

PHYSICAL EXAMINATION: Vital signs: Heart rate is 55 blood
pressure is 129/79 Respiratory rate is 22 O2 sat is 96
percent on 2 liters.

In general well-appearing man lying on a stretcher in no
acute distress. Neck: 2 plus carotids with no jugular
venous distention DISEASE and no bruits DISEASE and no thyromegaly. Lungs:
Fine crackles in the bases otherwise clear. Cardiovascular:
Regular rate and rhythm S1 and S2 with no murmurs rubs or
gallops. Abdomen: Soft and nontender and nondistended
normal active bowel sounds DISEASE and no bruits DISEASE . Pulses are 2 plus
femoral bilaterally 2 plus dorsalis pedis DISEASE as well as
posterior tibial bilaterally. No edema DISEASE . Neurological:
Alert and oriented times 3.

Chest CT done at the outside hospital showed no gallstones DISEASE .
Left kidney with a small cyst splenic lesion DISEASE and no triple A.
Electrocardiogram has sinus rhythm with Q wave in 2 3 and
F flattened T waves in the lateral leads sinus rhythm at a
rate of 56.

LABORATORY DATA: White blood cell count is 8.3 hematocrit
42.7 platelets 180 INR was 1.1 sodium 135 potassium 4.0
chloride 99 CO2 33 BUN 13 creatinine 1.0 glucose 96.
While on transfer the patient underwent cardiac
catheterization. Please see cathed report for full details.
In summary the catheterization showed left main with no
obstructive disease DISEASE LAD with 70 percent serial lesion left
circumflex with 70 percent proximal OM1 and OM2 both 70
percent lesions RCA with nonobstructive disease DISEASE and ejection
fraction of 25 percent.

The patient was referred to CT surgery who was seen and
accepted for coronary artery bypass grafting. On [**7-19**] he
was brought to the Operating Room please see the Operating
Room report for full details. In summary he had a coronary
artery bypass graft times 4 with a LIMA to the LAD saphenous
vein graft OM1 saphenous vein graft OM2 and saphenous vein
graft of the diagonal. His bypass time was 105 minutes with
a cross clamp time of 87 minutes. He tolerated the operation
well and was transferred from the Operating Room to the
cardiothoracic ICU.

At the time of transfer he was AV paced at a rate of 88
beats per minute. He had Propofol at 30 mc per kg per minute
and Neo-Synephrine to maintain his blood pressure. The
patient did well in the immediate postoperative period. His
anesthesia was reversed. He was weaned from the ventilator
and successfully extubated. He remained hemodynamically
stable throughout the remainder of his operative day. On
postoperative day 1 the patient remained hemodynamically
stable on a Neo-Synephrine drip to maintain an adequate blood
pressure. He remained in the Intensive Care Unit as he was
unable to be weaned off of his Neo-Synephrine drip.

On postoperative day 1 his Swan-Ganz catheter was removed as
well. On postoperative day 2 another attempt was made to
wean the patient off of Neo-Synephrine unsuccessfully. His
chest tubes were removed. However because he could not be
weaned from the Neo-Synephrine he again remained in the
Intensive Care Unit. On postoperative day 3 an additional
attempt was made to wean the patient from his Neo-Synephrine
unsuccessfully. The patient also received a unit of packed
red blood cells in an additional attempt to wean from Neo-
Synephrine. This also did not help in the attempt to wean
from Neo-Synephrine. His Foley catheter was removed and he
remained again in the ICU.

On postoperative day 4 additional attempts were made to wean
the patient off of his Neo-Synephrine however he continued
to drop his blood pressure whenever an attempt was made.
Other than that the patient remained completely stable. On
postoperative day 5 the patient was finally weaned off of
his Neo-Synephrine and diuresis was begun. He remained in
the Intensive Care Unit for an additional day to monitor his
hemodynamics. On postoperative day 6 the patient remained
hemodynamically stable and he was transferred to the floor
for continuing postoperative care and cardiac rehabilitation.
Over the next two days the patient had an uneventful
hospitalization. His activity level was increased with the
assistance of physical therapy department and the nursing
staff. On postoperative day 7 it was decided that the
patient would be stable and ready to be discharged to home on
the following day.

At the time of this dictation the patient's physical
examination is as follows: Vital signs were temperature 99
heart rate 84 in sinus rhythm blood pressure was 114/63
Respiratory rate was 18 O2 sat was 94 percent on room air.
Weight preoperatively was 88.5 kilos at discharge was 90.4
kilos.

LABORATORY DATA: White blood cell count 8.8 hematocrit
29.7 platelets 367 sodium 139 potassium 4.7 chloride 102
CO2 27 BUN 17 creatinine 1.1 glucose 95.

PHYSICAL EXAMINATION: Neurological: Alert and oriented times
3. Moves all extremities and follows commands. Respiratory:
Clear to auscultation bilaterally. Cardiovascular: Regular
rate and rhythm S1 and S2. No murmurs. Sternum is stable
incision with staples opened to air clean and dry DISEASE .
Abdomen: Soft and nontender nondistended with positive bowel
sounds. Extremities: Warm and well profuse with 1 to 2 plus
edema DISEASE . Right saphenous vein graft site with Steri-strips
open to air clean and dry DISEASE .

The patient's condition at discharge is good.

DISCHARGE DIAGNOSIS:
1. Coronary artery disease DISEASE status post coronary artery
bypass grafting times 4 with LIMA to the LAD saphenous
vein graft to OM1 saphenous vein graft to OM2 and
saphenous vein graft to the diagonal.
2. Hypertension DISEASE .
3. Hypercholesterolemia DISEASE .
4. Status post partial thyroidectomy.
5. Status post hernia DISEASE repair.
6. Status post left knee surgery.
7. Status post tonsil and adenoid surgery.


DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg q.d.
2. Plavix 75 mg q.d. times 3 months.
3. Aspirin 325 mg q.d.
4. Lasix 20 mg q.d. times two weeks.
5. Potassium chloride 20 mEq q.d. times two weeks.
6. Metoprolol 12.5 mg b.i.d.
7. Percocet 1 to 2 tabs q. 4 hours p.r.n.

The patient is to be discharged home with visiting nurses.
He is to have follow up in the wound clinic in two weeks and
follow up with Dr. [**Last Name (STitle) 3321**] in two to three weeks and
follow up with Dr. [**Last Name (STitle) **] in 4 weeks.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**] [**MD Number(1) 1715**]

Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2118-7-27**] 12:52:27
T: [**2118-7-27**] 13:28:05
Job#: [**Job Number 5364**]
Admission Date: [**2191-6-21**] Discharge Date: [**2191-6-24**]

Date of Birth: [**2133-2-24**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
transfer from cath lab s/p cardiac arrest DISEASE at OSH

Major Surgical or Invasive Procedure:
1. Cardiac Catheterization s/p LAD stent


History of Present Illness:
58 yo M with h/o HTN hyperlipidemia DISEASE no known CAD transferred
from OSH s/p V-fib arrest [**12-30**] AMI. Patient reports having chest
pain DISEASE back pain DISEASE under left scapula DISEASE and left shoulder pain DISEASE
starting at 6 pm on [**6-20**] while he was driving. He took 2 ASA at
that time the pain DISEASE stopped then started again later on. Patient
then went home and developed severe pain DISEASE while at rest which did
not resolve. He was driving to [**Hospital3 5365**] ED by his wife.
At the OSH patient found to have ST elevations in V2-V6 went
into V-fib s/p two shock DISEASE at 200J then 360 J (down 7 min per
flow sheet) patient started on lidocaine nitro gtt's
integrilin and heparin started. He was AAdmission Date: [**2155-2-18**] Discharge Date: [**2155-3-6**]

Date of Birth: [**2075-3-16**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 5368**]
Chief Complaint:
R arm shaking and confusion DISEASE

Major Surgical or Invasive Procedure:
Cystoscopy CKU procedure by Urology


History of Present Illness:
79 year old man with history of diabetes DISEASE and hypertension DISEASE who
presents with new onset seizures DISEASE . His wife found it unusual
that he picked her up from work late that day around 2 pm. When
they got home at arond 3:30pm he was staring straight at the TV
for 10 minutes and not responding to his wife. [**Name (NI) **] then
proceeded to go take his pills but his wife [**Name (NI) 5369**] him because
he had already taken them this morning. After the starring
episode his wife asked if he was okay but he kept repeating Admission Date: [**2162-3-3**] Discharge Date: [**2162-3-25**]

Date of Birth: [**2080-1-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
Mr. [**Known lastname 1829**] was seen at [**Hospital1 18**] after a mechanical fall from
a height of 10 feet. CT scan noted unstable fracture DISEASE of C6-7 &
posterior elements.

Major Surgical or Invasive Procedure:
1. Anterior cervical osteotomy C6-C7 with decompression and
excision of ossification DISEASE of the posterior longitudinal ligament.
2. Anterior cervical deformity DISEASE correction.
3. Interbody reconstruction.
4. Anterior cervical fusion C5-C6-C7.
5. Plate instrumentation C5-C6-C7.
6. Cervical laminectomy C6-C7 T1.
7. Posterior cervical arthrodesis C4-T1.
8. Cervical instrumentation C4-T1.
9. Arthrodesis augmentation with autograft allograft and
demineralized bone matrix.


History of Present Illness:
Mr. [**Known lastname 1829**] is a 82 year old male who had a slip DISEASE and fall
of approximately 10 feet from a balcony. He was ambulatory at
the scene. He presented to the ED here at [**Hospital1 18**]. CT scan
revealed unstable C spine fracture DISEASE . He was intubated secondary
to agitation DISEASE .

Patient admitted to trauma DISEASE surgery service

Past Medical History:
Coronary artery disease DISEASE s/p CABG
CHF DISEASE
HTN DISEASE
AICD
Atrial fibrillation DISEASE
Stroke DISEASE

Social History:
Patient recently discharged from [**Hospital1 **] for severe
depression DISEASE . Family reports patient was very sad and attempted to
kill himself by wrapping a telephone cord around his neck. Lives
with his elderly wife worked as a chemist in [**Country 532**].

Family History:
Non contributory

Physical Exam:
Phycial exam prior to surgery was not obtained since patient was
intubated and sedated.

Post surgical physical exam: (TSICU per surgery team)

Breathing without assistance
NAD
Vitals: T 97.5 HR 61 BP 145/67 RR22 SaO2 98
A-fib rate controlled
Abd soft non-tender
Anterior/Posterior cervical incisions [**Name (NI) 1830**]
Pt is edemitous in all four extremities no facial edema DISEASE
Able to grossly move all four extremities neurointact to light
touch
Distal pulses weakly intact

Medicine Consult:
VS: Tm/c 98.9 142/70 61 20 96%RA
I/O BM yesterday 220/770
Gen: awake calm cooperative and pleasant lying in bed
Neck: c-collar removed
CV: irregular normal S1 S2. No m/r/g.
lungs: cta anteriolry
Abd: Obese Soft NTND decreased bs
Ext: trace b/l le edema DISEASE 1Admission Date: [**2194-8-15**] Discharge Date: [**2194-8-16**]


Service: MEDICINE

Allergies DISEASE :
Lisinopril / Nsaids / Nesiritide

Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
HD DISEASE

History of Present Illness:
Ms. [**Known lastname **] is a 86F with h/o colon cancer ESRD DISEASE on
hemodialysis diastolic CHF pulmonary hypertension and prior
cephalic vein thrombosis DISEASE who presented to the ED on [**8-15**] with
dyspnea DISEASE .

The patient's dialysis catheter became dislodged [**8-12**].
Consequently she missed her normal dialysis session [**8-13**]. On
[**8-14**] she had a new tunneled catheter placed but was not
dialyzed. The afternoon of [**8-14**] her daughter noticed that the
patient seemed increasingly dyspneic and was hypertensive DISEASE to
200's. She was given hydralazine and clonidine and the BP
improved to 160's. She called her daughter Admission Date: [**2155-9-15**] Discharge Date: [**2155-9-22**]

Date of Birth: [**2075-3-16**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
Altered consciousness right arm shaking.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
The pt. is an 80 year-old right-handed gentleman who presented
on [**2155-9-15**] with several hours of decreased responsiveness. Per
the pt's wife the patient awoke around 6:00 on the morning of
admission and was mumbling seemed to have trembling DISEASE of lips. He
sat at the side of the bed and at 6:30 wife asked him to take
his medications and he has not responsive to her. He kept
repeating Admission Date: [**2119-11-23**] Discharge Date: [**2119-11-27**]


Service:

HISTORY OF PRESENT ILLNESS: This is an 83 year old woman
with myeloproliferative disorder DISEASE who is on a baby aspirin a
day who presented with melena DISEASE and coffee ground emesis DISEASE . Two
days prior to admission the patient was fatigued but
otherwise well. One day prior to admission the patient
started feeling diffuse abdominal pain DISEASE all day felt nausea DISEASE
vomiting DISEASE of coffee grounds in the evening and then melena DISEASE .
The patient admits to being lightheaded at that time with
increasing lightheadedness this morning.

She denies any chest pain palpitations shortness of breath cough orthopnea DISEASE sick contacts or suspicious foods. She
went to the Emergency Room where her vital signs revealed a
temperature of 97.9 F.Admission Date: [**2123-6-12**] Discharge Date: [**2123-6-18**]


Service: MEDICINE

Allergies DISEASE :
Enalapril

Attending:[**First Name3 (LF) 1845**]
Chief Complaint:
Bright red blood per rectum x 2

Major Surgical or Invasive Procedure:
Colonoscopy on [**2123-6-14**]


History of Present Illness:
86 yo woman with h/o diverticulosis DISEASE and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear/PUD
on PPI [**Last Name (NamePattern4) 5390**]/MDS presents with BRBPR. Pt was in her usual
health until 3am today when she woke up to have a BM. While
having BM noted Admission Date: [**2125-11-14**] Discharge Date: [**2125-11-20**]


Service: MEDICINE

Allergies DISEASE :
Enalapril / Amlodipine

Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a 89 year-old female with a history of MDS DISEASE hip
fracuture [**2-16**] living at [**Doctor Last Name 5396**]Rehab who presents with
shortness of breath DISEASE . Per nursing home staff patient has been
coughing with chest congestion fatigue DISEASE and poor PO intake for
1 week. Additionally staff states that she is the 4th patient
hospitalized for pnemonia and th 10th with chest cold symptoms DISEASE
and fevers DISEASE .
.
CXR on [**11-6**] was without cardiopulmonary process and labs were
significant for Hct of 60 WBC 26.3 (90%neut 1%lymph) Cr of
1.5 and proBNP of 6000 (3000 1 month earlier). Patient was
started on Lasix 40mg [**Hospital1 **] for presumed CHF DISEASE exacerbation but
continued to have cough fatigue DISEASE poor PO intake and on [**11-14**]
desated to the 70's.
.
In the ED patient's initial vitals were T 96.6 BP 111/58 HR
64 RR 30 sating 90% on NRB. While in ED she spiked to 101.8
with continued low sat on NRB DISEASE and was placed on BiPAP as patient
is DNR/DNI. BP dropped to 83/41 but responded to 1L NS back to
102/41. [**Month/Day (1) **] Cx sent and patient was given Vanc and Cefipime.
.
On ROS patient was oriented x 2 (did not know which hospital).
ROS likley inaccurate as patient denied Fevers/chills and SOB
which were documented in ED.
.


Past Medical History:
Myeloproliferative syndrome DISEASE
Hypothyroidism DISEASE
GI bleeds DISEASE diverticular last [**6-15**]
R bell's palsy
Hypertension DISEASE
Osteoporosis DISEASE
s/p hip fracture DISEASE with surgical treatment [**2-/2125**] ([**Hospital3 **])
One previous episode of atrial fibrillation DISEASE
.


Social History:
Has lived in rehab at [**Doctor Last Name 5396**]in [**Hospital1 **] since hip surgery
[**2-/2125**] ambulates with cane or walker.
No smoking quit 35 years ago about 20-30 pack year history no

alcohol no drug use.


Family History:
The patient's mother died of peritonitis DISEASE .
The patient's father had an unknown cancer DISEASE . No history of
gastrointestinal bleeding DISEASE in the family

Physical Exam:
Vitals: T: 98.5 BP: 102/42 HR: 97 RR: 17 O2Sat: 95% BiPAP 10/5
40%
GEN: No acute distress elderly woman mildly somnolent with
BiPAP mask on
HEENT: EOMI PERRL sclera anicteric no epistaxis DISEASE or
rhinorrhea MM dry
NECK: No JVD carotid pulses brisk no bruits no cervical
lymphadenopathy DISEASE trachea midline
COR: Tachy but regular no M/G/R normal S1 S2 radial pulses Admission Date: [**2136-10-23**] Discharge Date: [**2136-11-21**]

Date of Birth: [**2080-8-23**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS:
Patient is a 56-year-old woman previously healthy and began
developing a diffuse mild headache DISEASE and discomfort in [**Month (only) **].
Complained of left arm weakness toward the end of [**Month (only) 216**]
lasting a few minutes and since then has had four similar
episodes. Approximately a month ago she had slight change in
the character of the headache DISEASE . It is now constant diffuse
pain DISEASE with some nausea DISEASE [**7-20**] severity at its worse. In some
days is pain DISEASE free. No history of nonsteroidal
anti-inflammatory or aspirin use. Sometimes the occipital
portion of the headache DISEASE improves with sleep approximately the
same time she noted unsteady gait and falls to the left. She
had an occipital steroid injection with transient
improvement.

PAST MEDICAL HISTORY:
Benign.

PAST SURGICAL HISTORY:
Bowel surgery in [**2128**] for obstructive volvulus DISEASE .

REVIEW OF SYSTEMS:
General appearance: Denies fever or chills DISEASE . Positive weight
loss over the last three months [**4-19**] lb with no chest pain DISEASE
shortness of breath palpitations abdominal pain DISEASE no change
in bowel or urinary habits DISEASE .

PHYSICAL EXAMINATION:
Skin is warm and dry DISEASE . Head is normocephalic atraumatic.
Eyes: Sclerae are anicteric. Throat: Pharynx is pink
clear without exudate DISEASE or drainage. Teeth intact. Gums are
pink and moist. Tongue normal. Neck is supple without
jugular venous distention DISEASE . Heart regular rate and rhythm
without murmurs rubs or gallops. Chest was clear to
auscultation. Abdomen is soft nondistended positive bowel
sounds. Extremities: No clubbing cyanosis DISEASE or edema DISEASE .
Neurologically visual fields are full to confrontation. Her
pupils are equal round and reactive to light. Her cranial
nerves are intact. Her motor strength is [**4-14**] in all muscle
groups. Her reflexes are 2Admission Date: [**2140-1-16**] Discharge Date: [**2140-1-23**]


Service:

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: This is an 86 year old female
who has had recent multiple admissions to the hospital for
shortness of breath DISEASE who was admitted on [**2140-1-16**] from
rehabilitation with listlessness DISEASE and a blood pressure in the
low range of 100/60. She also had an oxygen saturation of
88% on two liters. The patient's primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 3357**] assessed the patient and she was sent to [**Hospital1 346**] Emergency Department for evaluation
for congestive heart failure DISEASE . She had some wheezes on
examination and was given Albuterol and Ipratropium
nebulizers and Lasix 40 mg intravenously. Her blood pressure
on admission to Emergency Department triage was approximately
80/60 which was lowered to 74/23. Dopamine drip was started
for blood pressure support and the patient was admitted to
Intensive Care Unit and given two liters of normal saline.
She was noted to be 88% in room air and got antibiotics for
possible pneumonia DISEASE . She was placed on an eight liter face
mask and had an arterial blood gases of 7.30 with a pCO2 of
47 and a pO2 of 58. She was in the Intensive Care Unit for
three hospital days and was transferred out to the Medicine
floor after it was determined that she was likely dehydrated
and went into renal failure DISEASE due to dehydration DISEASE and possible
over diuresis.

PAST MEDICAL HISTORY:
1. Multi-infarct dementia DISEASE .
2. Coronary artery disease status post pacer for complete
heart block DISEASE .
3. Diabetes mellitus DISEASE .
4. Depression.
5. Congestive heart failure DISEASE .
6. Status post radial fracture DISEASE .
7. Bilateral knee arthroplasty.

MEDICATIONS ON ADMISSION:
1. Colace.
2. Vitamin D.
3. Lipitor 10 mg p.o. once daily.
4. Aspirin 81 mg p.o. once daily.
5. Lopressor 50 mg p.o. twice a day.
6. Imdur 90 mg p.o. once daily.
7. Lisinopril 20 mg p.o. once daily.
8. Ultram 50 mg p.o four times a day.
9. Protonix 40 mg p.o. once daily.
10. Lasix 20 mg p.o. once daily.
11. Zyprexa 10 mg p.o. twice a day.
12. Effexor 75 mg p.o. once daily.
13. Effexor XR 150 mg p.o. q.h.s.
14. Neurontin 300 mg p.o. twice a day.

PHYSICAL EXAMINATION: Upon presentation to Medicine
temperature is 96.9 blood pressure 103/63 heart rate 86
respiratory rate 27 oxygen saturation 96% in room air. In
general she is sitting in bed bright and alert. Head
eyes ears nose and throat examination reveals moist mucous
membranes with a clear oropharynx. The lungs show slight
crackles at the left base and no audible wheezes.
Cardiovascular reveals a regular rate and rhythm with distant
heart sounds. Abdomen is soft obese nontender
nondistended with positive bowel sounds. Extremities show no
pedal edema DISEASE .

LABORATORY DATA: Upon presentation to Medicine white blood
cell count was 9.1 hematocrit 35.6 platelet count 326000.
Creatinine 1.1 blood urea nitrogen 27 potassium 5.2
glucose 171.

HOSPITAL COURSE:
1. Dyspnea hypoxia DISEASE - She was much improved after getting
fluids in the Intensive Care Unit without any diuresis. It
was determined by chest x-ray that she was dry DISEASE and had
possible infiltrate and was treated with antibiotics
Levofloxacin Flagyl Vancomycin. The Vancomycin was
discontinued however she remained on Levofloxacin and
Flagyl for concern of aspiration pneumonia DISEASE . Intensive Care
Unit team also felt that the patient had reactive airways and
started steroids p.o. along with continuing nebulizers. She
had a negative infectious workup to date. Of note she has
not had a history of chronic obstructive pulmonary disease DISEASE or
asthma DISEASE in the past. Upon transfer to the Medicine floor she
was found the next day to be in significant respiratory
distress requiring respirator care and nebulizers. She
seemed to do better after this. Chest x-ray was obtained and
showed progressive heart failure DISEASE over the past four days in
the hospital. She was given 20 mg intravenous Lasix and had
good urine output and was saturating well. She then became
very lethargic and was given intravenous fluids as it is
noted in the past the patient responds very well to
intravenous fluids becoming more alert and aware of her
environment. Also of note the patient had a transthoracic
echocardiogram which showed an ejection fraction of 55% and
E:A ratio of 0.82 however this did not meet criteria for
diastolic dysfunction DISEASE . She also had a very poor quality
echocardiogram which limited our evaluation of whether she
has systolic dysfunction DISEASE in addition to diastolic
dysfunction. A heart failure DISEASE consultation was obtained by Dr.
[**Last Name (STitle) **] and it was determined that it was difficult to tell
whether she had pure diastolic dysfunction DISEASE . It was
recommended that the patient start Diltiazem for rate control
without using beta blockers to exacerbate any potential
bronchospasm DISEASE . The patient did well on Diltiazem and was
continued only on Lisinopril 5 mg p.o. once daily. Her
previous Imdur and Lopressor were discontinued.

2. Hypotension DISEASE - It was unclear whether the patient was
overmedicated with blood pressure medications upon admission
or was over-diuresed. Her previous hospital stay had
actually cut down her previous Lasix dose so it is unclear
whether this had anything to do with her hypotension DISEASE .
However while in house the patient's blood pressure
remained well without Lopressor or Lisinopril at 20 mg. At
the reduced Lisinopril dose as well as the Diltiazem the
patient did well. She was restarted on her Lasix 20 mg p.o.
Once daily.

CONDITION ON DISCHARGE: Good.

DISCHARGE STATUS: To [**Hospital 5412**] Rehabilitation.

DISCHARGE DIAGNOSES:
1. Multi-infarct dementia DISEASE .
2. Coronary artery disease status post pacer for complete
heart block DISEASE .
3. Diabetes mellitus DISEASE .
4. Depression.
5. Congestive heart failure DISEASE .
6. Status post radial fracture DISEASE .
7. Bilateral knee arthroplasty.

MEDICATIONS ON DISCHARGE:
1. Diltiazem XR 120 mg p.o. once daily hold for systolic
blood pressure of less than 110.
2. Prednisone 40 mg p.o. twice a day on a taper to decrease
by 10 mg twice a day every two days.
3. Metronidazole 500 mg p.o. three times a day.
4. [**2140-1-23**] is her last day of Levofloxacin 250 mg p.o.
once daily.
5. [**2140-1-23**] is her last day of Acetamodic.
6. Gabapentin 300 mg p.o. twice a day.
7. Phenylfaxene SR 75 mg p.o. once daily.
8. Lisinopril 5 mg p.o. once daily.
9. Ipratropium MDI two puffs inhaled four times a day.
10. Albuterol MDI one to two puffs inhaled q4hours p.r.n.
11. Olanzapine 10 mg p.o. twice a day.
12. Vitamin D 400 units p.o. once daily.
13. Docusate 100 mg p.o. twice a day.
14. Aspirin 81 mg p.o. once daily.
15. Atorvastatin 10 mg p.o. once daily.

FOLLOW-UP PLANS: The patient is to follow-up with her
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**].




[**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 1197**]

Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36

D: [**2140-1-23**] 08:39
T: [**2140-1-23**] 09:13
JOB#: [**Job Number 5413**]
Admission Date: [**2140-4-23**] Discharge Date: [**2140-4-27**]


Service: ACOVE

HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 5419**] is an 87 year-old
Russian female with a past medical history significant for
multi infarct dementia coronary artery disease DISEASE diastolic
dysfunction type 2 diabetes DISEASE pacemaker for heart block DISEASE deep
venous thrombosis DISEASE and PE and aspiration of thin liquids who
presented from her nursing home on [**2140-4-23**] after the
caretakers at the nursing home noticed an area of erythema DISEASE
and tenderness DISEASE on the patient's left lower concern. Their
concern was for a cellulitis DISEASE . The patient was also noted to
be sleepy more so then her baseline with a decreased room air
saturation. In the Emergency Department the patient was
afebrile. She was in no acute distress. There was an area
on her left lateral upper calf that was erythematous and
slightly warm likely a cellulitis DISEASE . The patient was treated
with Ancef 1 gram intravenous. She was also given Flagyl 500
mg intravenous and Levaquin 500 mg intravenous for question
of an aspiration pneumonia DISEASE with the patient's history of
aspiration and the drop in room air sats to 89%. This
saturation improved to 97% on 2 liters. The patient had a
chest x-ray that was read s fluid in the fissure but cannot
rule out a retrocardiac infiltrate. Therefore the patient
was admitted for management of cellulitis DISEASE and possible
pneumonia DISEASE .

PAST MEDICAL HISTORY:
1. Multi infarct dementia DISEASE . At baseline the patient is not
alert and oriented times three but is responsive.
2. Coronary artery disease DISEASE .
3. Congestive heart failure DISEASE diastolic last EF from
echocardiogram on [**2140-2-23**] was super normal read as 75 to 80%
with an E to A ratio of 0.55 normal left ventricular wall
thickness.
4. Diabetes mellitus DISEASE type 2.
5. Pacemaker for complete heart block DISEASE .
6. Depression.
7. Status post cataract DISEASE surgery.
8. Hypertension DISEASE .
9. Diagnosed with deep venous thrombosis DISEASE and PE in [**2140-2-13**] now on Coumadin.
10. History of E-coli urinary tract infection DISEASE resistant to
Levofloxacin.
11. Pneumonia DISEASE in [**2140-1-13**] possibly related to
aspiration.
12. Aspiration of thin liquids. The patient had a speech
and swallow study on [**2140-1-21**] that was interpreted as
aspiration of thin liquids with the recommendation that the
patient have nectar thick liquids and purees and be
positioned upright for all po intake.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS ON ADMISSION:
1. Colace 100 b.i.d.
2. Vitamin D 400 units q.d.
3. Lipitor 10 q.d.
4. Aspirin 81 q.d.
5. Effexor 75 q.d.
6. Neurontin 300 b.i.d.
7. Protonix 40 q.d.
8. Lasix 20 mg q 72 hours.
9. Zyprexa 10 b.i.d.
10. Coumadin 2 mg q.d.
11. Albuterol MDI.
12. Atrovent MDI.
13. Regular insulin sliding scale.

SOCIAL HISTORY: The patient speaks only Russian. She lives
in a nursing home and has resided there for at least five
years. Her son is very involved in her care.

PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.9. Pulse
62 and regular. Blood pressure 118/54. Respiratory rate 20.
Sat 97% on 2 liters. In general the patient was felt to be
ill appearing and in no acute distress very sleepy uneasy
to arouse. HEENT mucous membranes are dry DISEASE . Pupils are
equal round and reactive to light and accommodation. Neck
supple. Lungs clear to auscultation bilaterally with diffuse
expiratory wheezing DISEASE . Cardiovascular distant heart sounds DISEASE S1
and S2 2 out of 6 systolic ejection murmur DISEASE at the right
upper sternal border. Abdomen soft obese nontender
positive bowel sounds. Extremities area on the left upper
calf of erythema DISEASE roughly 2 cm by 2 cm nonpainful nontender
no skin breakdown or open areas. Neurological sleepy opens
eyes to commands otherwise cannot comply well with
neurological examination. Per records this is the patient's
baseline.

LABORATORY DATA ON ADMISSION: White blood cell count 10.5
hematocrit 33.2 platelets 351 creatinine 1.0 glucose 157
INR 1.6.

IMAGING: The patient had a left lower extremity ultrasound
which showed no evidence of deep venous thrombosis DISEASE . Chest
x-ray showed slight obscurating of the left hemidiaphragm
question infiltrate.

IMPRESSION: This is an 87 year-old Russian only speaking
female with multiple medical problems including dementia DISEASE
coronary artery disease congestive heart failure DISEASE deep
venous thrombosis DISEASE and PE presenting with a left leg
cellulitis DISEASE .

For the patient's cellulitis DISEASE she was initially continued on
Unasyn with her history of diabetes DISEASE and a concern for a
complicated infection DISEASE . For the question of pneumonia DISEASE the
patient was not placed on antibiotics as it was felt that she
did not have a pneumonia DISEASE based on the absence of an elevated
white count the absence of cough DISEASE or fever DISEASE and the absence of
sputum production. For the patient's recent history of PE
and deep venous thrombosis DISEASE with an INR of only 1.6 the
patient was continued on Coumadin and also given Lovenox
until her INR was therapeutic.

HOSPITAL COURSE: 1. Infectious disease: For the patient's
presumed cellulitis DISEASE she was treated with Dicloxacillin 250 mg
po q.i.d. The Unasyn was discontinued as even though the
patient is a diabetic DISEASE she had no open areas and the
cellulitis DISEASE appeared very mild and there was no skin
breakdown. There was improvement in her cellulitis DISEASE during
her hospital stay with a po Dicloxacillin. The patient was
ruled out for other etiologies of infection DISEASE . The chest x-ray
appeared without infiltrate. Her urine showed no evidence of
infection DISEASE . The patient remained afebrile.

2. Hematology: The patient's INR by the morning of hospital
day number two was 2.3 therefore the Lovenox was
discontinued and the patient was continued on Coumadin.

3. Hypotension: The patient is on a dosing regimen of Lasix
20 po q 72 hours for her history of diastolic dysfunction DISEASE .
She was continued on this while in house initially. On the
evening of [**2140-4-23**] the house staff was called to see the
patient for tachypnea DISEASE decreased O2 sats to 88% on room air.
The patient was normotensive at this time. On physical
examination she was tachypneic with a respiratory rate in the
30s. She was diaphoretic in appearance with diffuse
expiratory wheezing DISEASE on lung examination without crackles. On
examination of her extremities she had 1Admission Date: [**2153-9-25**] Discharge Date: [**2153-9-28**]

Date of Birth: [**2090-1-5**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p EtOH ablation of interventricular septum for Hypertrophic obstructive cardiomyopathy DISEASE

Major Surgical or Invasive Procedure:
Ethanol ablation of Myocardial interventricular septum


History of Present Illness:
Patient is a 63 yo male with PMH significant for hypertrophic
cardiomyopathy COPD hypertension DISEASE and recently diagnosed Afib DISEASE
admitted after undergoing EtOH ablation of the interventricular
septum. The patient has had DOE with chest pressure since 1
year. Says that he used to get SOB and CP while walking up only
a slight incline. He denies symptoms at rest. He does have
periodic leg edema DISEASE which he treats with diuretics. He sleeps on
two pillows for comfort. Denies claudication DISEASE PND
lightheadedness. Gives h/o occasional palpitations DISEASE of about few
seconds since 1 year. In early [**2153-8-19**] pt had CP and
diaphoresis DISEASE at rest which subsided after some time. Next day he
went to play golf but soon developed SOB and CP and had to be
admitted to [**Hospital3 **]. Troponin was borderline positive/CK's
negative and he was transferred to [**Hospital1 18**] for cardiac
catheterization which revealed a significant subaortic valve
pressure gradient that increased with Valsalva. He was found in
atrial fibrillation DISEASE during the admission and discharged on
Coumadin which he stopped taking on [**9-18**]. He now came in
for ethanol ablation of the myocardial interventricular septum.

Past Medical History:
1)Hypertrophic cardiomyopathy DISEASE (diagnosed 3 years ago)
2)Hypertension
3)COPD
4)Low back pain DISEASE secondary to herniated disc DISEASE
5)Atrial fibrillation DISEASE (newly diagnosed)
6)s/p Cataract surgery
7)Remote knee surgeries
8)Thalasemia minor

Social History:
Patient is single and lives alone. He has two chdilren.
Pt smoked 1ppd x 40-50yrs and quit 10 yrs ago.
1-2 beers/day


Family History:
Mother w/MI

Physical Exam:
vitals BP 142/73 HR 40-50 (irregular) RR 14 O2 Sat Admission Date: [**2166-3-21**] Discharge Date: [**2166-4-4**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain DISEASE radiating to back


Major Surgical or Invasive Procedure:
Emergency repair of acute type A aortic dissection with
ascending aortic and hemiarch replacement with a size 26
Gelweave graft.
Aortic valve resuspension.


History of Present Illness:
[**Age over 90 **]yo F BIBA from home c/o chest pain DISEASE radiating to back. In
EDpt acutely decompensated becoming tachycardic
hypotensiveunresponsive. She was intubated. Hemodynamics
improved on dopamine. Echo reveals pericardial effusion DISEASE with
tamponade DISEASE CXR reportedly reveals widened mediastinum. Cardiac
surgery is called for emergent evaluation. She does have a h/o
asc. aortic
aneurysm DISEASE of 4.2cm

Past Medical History:
- Diastolic CHF DISEASE last echo [**10-29**] with (LVEFAdmission Date: [**2131-6-9**] Discharge Date: [**2131-6-16**]

Date of Birth: [**2064-5-17**] Sex: F

Service: [**Hospital1 **]

HISTORY OF PRESENT ILLNESS: The patient is a 67 year old
female with a long medical history including atrial
fibrillation DISEASE without Coumadin (the patient declined)
supraventricular tachycardia DISEASE post ablation times two
multiple sclerosis myasthenia DISEASE [**Last Name (un) 2902**] migraines DISEASE and
prescription medication abuse who presented to the Emergency
Room on [**2131-6-8**] complaining of episodic speech arrest DISEASE
for two days and nausea diarrhea DISEASE and headache DISEASE for one day.
The patient was in her usual state of health until [**2131-6-6**] when she experienced several episodes of speech arrest DISEASE
while in the car with her husband. The next day she awoke
with severe headache DISEASE and nausea DISEASE with diarrhea DISEASE and vomiting DISEASE
times four in addition to her episodic speech arrest DISEASE .

Her primary care physician saw her and drew blood which
revealed a potassium of 2.9. MRI showed periventricular
white matter changes by the inferior [**Doctor Last Name 534**] of the right
lateral ventricle as well as left mastoiditis DISEASE . Her symptoms
continued the next day with headache DISEASE and vomiting DISEASE times two
as well as speech arrest DISEASE . The patient went to the [**Hospital1 1444**] Emergency Department.

In the Emergency Room her vital signs were temperature 97.0
F.Admission Date: [**2198-7-17**] Discharge Date: [**2198-8-4**]

Date of Birth: [**2132-6-25**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
[**2198-7-25**]
1. Left atrial appendage resection.
2. Coronary artery bypass grafting x3: Left internal
mammary artery to left anterior descending artery and
reverse saphenous vein graft to the posterior descending
artery and obtuse marginal artery.
3. Aortic valve replacement with a 25-mm St. [**Male First Name (un) 923**] Epic
tissue valve model #EFT100-25- 00.


History of Present Illness:
66 year old male who presented with worsening shortness of
breath and hypotension DISEASE . He presented to his PCP's office for
follow up and was noted to be short of breath and hypotensive DISEASE
with SBP's in the 80's. His symptoms
started approximately 2-3 weeks prior to presentation. He mainly
had difficulty with shortness of breath DISEASE . This shortness of
breath
would prevent him from sleeping comfortably. He describes
symptoms consistent with orthopnea DISEASE and PND. He notes that he saw
Dr. [**Last Name (STitle) **] a couple of weeks ago and was started on lasix and
aldactone. He was also noted to be in atrial fibrillation DISEASE at
that
time as well. He is now being referred to cardiac surgery for
evaluation of revascularization and possible aortic valve
replacement.


Past Medical History:
Atrial fibrillation DISEASE
Coronary Artery Disease DISEASE
Aortic Stenosis DISEASE
PMH:
Diastolic and Systolic CHF DISEASE (EF 30-35%)
Type 2 diabetes DISEASE
Hypertension DISEASE
Hypercholesterolemia DISEASE
Chronic Back Pain DISEASE
degenerative neurological disease DISEASE Admission Date: [**2161-2-2**] Discharge Date: [**2161-2-26**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
hypotension DISEASE mental status changes respiratory distress/failure DISEASE

Major Surgical or Invasive Procedure:
R-sided Femoral line
R-PICC
Tracheostomy
Pleurex Catheter Placed-L sided


History of Present Illness:
[**Age over 90 **] yo M with hx of hypothyroidism Afib DISEASE CAD HTN DISEASE new diagnosis
of GE junction lymphoma DISEASE (s/p 3 months of radiation therapy with
tumor DISEASE size [**1-5**] as before but now no longer candidate for
radiation therapy) who presents from [**Hospital 100**] Rehab with call0in
with tachypnea DISEASE RR 40's with frequent suctioning of very thick
mucous.
.
Came from [**Hospital 100**] Rehab with complaints of SOB and DOE. He got
Morphine 8mg po x 1 at [**Hospital 100**] Rehab prior to transfer and
subsequently developed mental status changes. On arrival he was
noted to have temp 101 BP 70/p HR 120's RR6 99% on 100% NRB.
He was given IVF wide open 2mg Narcan DISEASE with Admission Date: [**2161-3-7**] Discharge Date: [**2161-3-10**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Change in MS

Major Surgical or Invasive Procedure:
femoral line placement PICC line placement [**3-8**]

History of Present Illness:
Patient is a [**Age over 90 **] yo vent dependent male with hx of hypothyroid DISEASE
cad s/p cabg ef 45% htn ge junction lymphoma DISEASE who presents
from [**Hospital 100**] rehab for change for tachypnea DISEASE and tachycardia DISEASE while
recieving 1 u prbc for hct 24.4. He was given lasix and found
to have new lbbb on ekg. He was also found to be febrile DISEASE 100.4.
He was started on levoflox.
.
He was febrile DISEASE in the ED to 102.8 HR 90 and was initially
normotensive 129/66 however a few hours later became
hypotensive DISEASE (of note had rec'd 2mg iv morphine and 40 mg of
lasix at that time). Patient was started on the sepsis DISEASE protocol
but in the setting of profound hypotension DISEASE a femoral line was
placed. Blood and urine cultures were obtained and patient was
given vanc levo flagyl. He was also given hydrocortisone and
levophed.


Past Medical History:
Hypothyroidism DISEASE CAD s/p MI [**2142**] EF 45% HTN DISEASE BPH Depression DISEASE
High cholesterol GE Junction lymphoma DISEASE (s/p 3 months of
radiation therapy with tumor DISEASE size [**1-5**] as before but now no
longer candidate for
radiation therapy) peripheral T cell lymphoma

Social History:
Moved from [**Country 532**] 10 years ago
former engineer
wife with alzheimer's disease DISEASE
lives alone walks with cane
No ETOH tobacco
his baseline activity -
At baseline does not walk. Speaks in full conversations but has
lapses of memory at times.

Family History:
No h/o CAD

Physical Exam:
Vitals: T BP 100/63 HR 59 afib 100% on AC rr 10 tv 500
Gen: ill appearing male in no app. resp distress
HEENT: trach opens eyes perrla
Lungs: bibasilar crackles
Heart: s1 s2 irreg irreg
Abd: soft peg tube in place
Ext: 2Admission Date: [**2117-3-4**] Discharge Date: [**2117-3-10**]


Service: SURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Right upper quadrant pain DISEASE

Major Surgical or Invasive Procedure:
[**2117-3-4**]
Laparoscopic cholecystectomy


History of Present Illness:
This is a [**Age over 90 **]M with a history of DM2 DISEASE presenting with severe
RUQ since last night. He's actually had intermittent mild pain DISEASE
x
9 days (Admission Date: [**2132-12-8**] Discharge Date: [**2132-12-14**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
cardiac catheterization

History of Present Illness:
Ms [**Known lastname 5448**] is an 89yo pt with h/o CAD s/p RCA stent in [**2124**]
a-fib on warfarin and dofetilide who presented to OSH on
[**2132-12-7**] with CHF DISEASE exacerbation. BNP was 326 (1-100). CT ruled
out PE but showed extensive metastatic disease to pleura.
Initial tropI was negative but the 2nd tropI was positive at
1.43 at 7AM and 1.79 at 12:30PM. EKG showed e/o possible prior
septal infarct DISEASE no acute ST changes. Cardiology saw her and felt
that given her age and comorbidity (breast cancer DISEASE w/mets) she
is not suitable for further intervention and recommended medical
management. Pt was started on nitro patch. However her primary
cardiologist (Dr. [**Last Name (STitle) **] felt otherwise and was willing to cath
her so she was transferred to [**Hospital1 18**] for catheterization. Per
report she had an episode of chest pain DISEASE that responded to nitro
this afternoon. Also after speaking with medical team at OSH
the discussion was had about her code status and decision was
made DNR.
.
At home pt reports passing out 5 days ago. She was getting into
bed felt SOB lost consciousness for a couple of minutes. She
reports hitting her head on the left side of her forehead on a
thick rug. Her sons were with her. Episode of SOB while watching
TV as well as Admission Date: [**2115-11-6**] Discharge Date: [**2115-11-26**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
Hypotension DISEASE

Major Surgical or Invasive Procedure:
CyberKnife mapping


History of Present Illness:
Dr. [**Known lastname 5459**] is an 85 year old gentleman with history of COPD DISEASE on
6L home O2 (FEV1 28% predicted) recurrent DVT DISEASE on coumadin and
recently diagnosed LUL NSCLC DISEASE who is admitted with hypotension DISEASE .
Today he was scheduled for LUL fiducial electrode placement and
was noted to have relative hypotension DISEASE with [**Name (NI) 5462**] in the 90's.
.
His primary oncologist noted L Admission Date: [**2115-2-7**] Discharge Date: [**2115-2-12**]

Date of Birth: [**2056-11-8**] Sex: M

Service: CARDIOVASCULAR

CHIEF COMPLAINT: Persistent chest pain DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 58 year-old
Caucasian male with a past medical history significant for
coronary artery disease DISEASE status post four vessel coronary
artery bypass graft in [**2106**] who underwent evaluation of
chest and upper arm discomfort times several weeks. In
addition the patient was also experiencing exertional DISEASE chest
pain DISEASE and dyspnea DISEASE on exertion after one flight of stairs. On
[**2115-1-10**] the patient underwent an ETT thallium and
exercise for seven minutes by [**Doctor First Name **] protocol with chest pain DISEASE
but no significant EKG changes on a normal thallium study.
The patient was admitted to the CMI Service on [**2115-2-7**]
and underwent coronary catheterization that same day. During
this catheterization LV gram revealed a sustained ejection
fraction at 60% with evidence of a 70% proximal and 50% mid
stenosis of the SVT DISEASE to PDA graft and a 30% proximal stenosis
of the SVG to OM2 graft as well as a 99% proximal stenosis of
the SVG to D1 graft.

The patient underwent PTCA and stent placement with no
residual stenosis of the SVG to D1 graft on the 8th with no
complications at that time. Notably the patient also was
with a patent LIMA to LAD graft during his first
catheterization. On the [**2-8**] the patient returned to
the catheterization laboratory and underwent a percu-surge
device procedure for the SVG to PDA lesion. Notably this
artery had diffuse disease proximally with 80% ulcerated
stenosis and 40% mid stenosis. The patient underwent PTCA
and stent with observation of TIMI-2 fast flow. This
procedure was complicated by evidence of distal embolization
of the plaque DISEASE during the procedure. Hemodynamic monitoring
at this catheterization revealed RA pressure of 7 pulmonary
capillary wedge pressure of 7 cardiac index of 2.5 with a
patent SVG to D1 stent. The patient was kept on Integrilin
with a goal of 48 hours total therapy secondary to his
complicated catheterization.

Several hours after his second cath on [**2-8**] the patient
had an acute drop in his systolic blood pressures to the
70's. He responded with elevation of pressures after 500 cc
IV fluid bolus. Telemetry also showed three episodes of five
beat nonsustained ventricular tachycardia DISEASE . On the morning of


the 10th the patient was complaining of pleuritic chest pain DISEASE
and mild shortness of breath DISEASE . CKs at this time were checked
and were notably rising compared to the prior day. EKG at
this time revealed ST segment elevation of .5 to 1 mm in lead
3 AVF and precordial lead V2 to V4 ST depressions. Later in
the evening the patient continued to have constant chest pain DISEASE
associated only with shortness of breath DISEASE . The pain DISEASE improved
in the semi-upright position however the patient had
minimal relief with increasing of an IV nitroglycerin drip or
morphine. After consultation of the interventional
cardiology fellow it was believed that the patient was likely
having a subacute myocardial infarction DISEASE as indicated by
ischemic changes on EKG and persistent chest discomfort post
cath in the setting of a complicated catheterization with
evidence of distal embolization. It was the impression of
the staff interventional cardiologist that the patient was
not suitable to take back to the catheterization laboratory
since there was no suitable therapy for small vessel distal
embolization. The patient was transferred to the Coronary
Care Unit at this time for hemodynamic monitoring and for
close observation.

PAST MEDICAL HISTORY: 1. Coronary artery disease DISEASE status
post four vessel coronary artery bypass graft in [**2106**] with a
LIMA to LAD graft SVG to OM2 SVG to D1 and SVG to PDA. 2.
Hypercholesterolemia DISEASE . 3. Hypertension. 4. History of
tobacco use.

ALLERGIES: The patient has no known drug allergies DISEASE .

MEDICATIONS ON TRANSFER: 1. Aspirin 325 mg po q day. 2.
Plavix 75 mg po q.d. 3. Zestril 5 mg po q.d. 4.
Hydrochlorothiazide 12.5 q day. 5. Lipitor 10 mg po q.d.
6. Meclozine 12.5 t.i.d. 7. Integrilin at 15 cc per hour
times 48 hours. 8. IV nitroglycerin drip. 9. Percocet
prn. 10. Morphine sulfate prn.

SOCIAL HISTORY: The patient works in home room modeling and
construction. Occasional social alcohol use. He does not
participate in any formal exercise program. He is married
and has grown children. Tobacco history as above. The
patient is a former smoker.

PHYSICAL EXAMINATION: Vital signs on transfer temperature
101.4. Pulse 122. Blood pressure 100/45. Pulse 110.
Respirations 18. O2 saturation is 100% on 2 liters. 24 hour
I and O are 11 35 and over 24 25 outs. General the patient
is a well appearing Caucasian male in no acute distress.
HEENT head is normocephalic atraumatic. Sclera and
conjunctiva are anicteric. Oropharynx is clear without
erythema DISEASE or exudate DISEASE . Neck is without evidence of JVD and


supple without obvious lymphadenopathy DISEASE . Chest is clear to
auscultation bilaterally. Cardiovascular examination reveals
a normal S1 S2 sinus tachycardia DISEASE with a questionable
pericardial rub and 2Admission Date: [**2120-7-22**] Discharge Date: [**2120-7-25**]

Date of Birth: [**2056-11-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
cardiac cath

History of Present Illness:
63 year-old M with CAD s/p CABG ([**2106**] - LIMA to LAD SVG to OM2
SVG to D1 SVG to PDA) s/p PTCA ([**2114**] - stents placed to SVG to
D1 graft and SVG to PDA graft) who presented with chest pain DISEASE to
OSH transferred here for cardiac cath now s/p cath. He awoke
from sleep at home with 8/10 chest pain DISEASE L arm discomfort and
diaphoresis DISEASE . No SOB or nausea DISEASE . He arose and felt lightheaded
and proceeded to have a syncopal DISEASE event. No trauma DISEASE . He went to
the OSH ED at 2 am for evaluationAdmission Date: [**2172-3-1**] Discharge Date: [**2172-3-9**]

Date of Birth: [**2117-3-16**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: This is a 54-year-old white
female with a history of hypertension DISEASE and diet controlled
diabetes mellitus DISEASE and possible systemic lupus erythematosus DISEASE .
Several hours prior to admission the patient noted a sinus
type headache DISEASE with tightness DISEASE in the frontal area nose eyes
and took sinus medications without relief. The headache DISEASE
persisted and she also developed associated neck pain DISEASE and
bilateral shoulder. She found it difficult to sleep. She
took some Tylenol and still had no relief and subsequent to
this the patient headache DISEASE persisted and she presented to the
Emergency Room with persistent headache DISEASE and was found to have
difficulty remembering whether the headache DISEASE had come on
suddenly and denied any associated nausea vomiting DISEASE
diarrhea constipation weakness DISEASE or further numbness DISEASE or
neurologic symptoms.

PREVIOUS MEDICAL HISTORY: History of low back pain DISEASE history
of hypertension DISEASE times ten years history of noninsulin DISEASE
dependent diet controlled diabetes DISEASE history of a tubal
ligation and a past history of migraine headaches DISEASE .

CURRENT MEDICATIONS: Zestril 20 mg q.d. nifedipine 30 mg
q.d. and Prempro 2.5 mg q.d.

ALLERGIES: She has an allergic history reaction DISEASE to
penicillin.

SOCIAL HISTORY: She works as a administrative assistant at
the [**Hospital6 256**].

FAMILY HISTORY: Positive for sarcoid DISEASE in her mother.

PHYSICAL EXAMINATION: The patient was noted to be a healthy
but obese female in no acute distress. Neurological exam
shows awake alert and oriented times three with fluent
speech normal language DISEASE and comprehension. Pupils equal
round and reactive to light and accommodation. Extraocular
movements intact and visual fields were full to
confrontation. The face was symmetric and sensation was
intact to light touch. The tongue and uvula were midline and
the remainder of the cranial nerve exam was unremarkable.
Reflexes were 2Admission Date: [**2190-6-12**] Discharge Date: [**2190-6-15**]

Date of Birth: [**2146-5-23**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Percocet

Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Alcohol Intoxication

Major Surgical or Invasive Procedure:
Endoctrachial intubation


History of Present Illness:
44 y.o. male with history of numerous ED visits (6 ED visits
since [**2189-3-11**]) for alcohol intoxication presents via [**Location (un) 86**]
EMS from local neighborhood attempting to get on public
tranportation. Pint of vodka was found on pt and states Admission Date: [**2161-3-19**] Discharge Date: [**2161-3-30**]


Service: MEDICINE

Allergies DISEASE :
Codeine / Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Rectal bleeding DISEASE

Major Surgical or Invasive Procedure:
-Angiography
-Subclavian cordis / left subclavian central line placed [**3-21**]
removed [**3-23**]
-Colonoscopy

History of Present Illness:
Mrs. [**Known lastname 5480**] is a [**Age over 90 **]-year-old female with a PMH significant
for Celiac Disease hemorrhoids DISEASE old CVA DISEASE ([**2153**]) hypertension DISEASE
hypothyroidism DISEASE and known cecal AVM DISEASE who was recently admitted to
[**Hospital3 **] ([**3-14**]) with a large GIB DISEASE 5 days prior to this
admission. At that time her Hct was 19 NGL negative transfused
several units of blood to bring her Hct up to 35. No colonoscopy
performed given her overall good clinical stability and
discussion about risks/benefit of procedure. Patient was
discharged home yesterday and was doing well until the day of
admission to this hospital when she had several episodes of
BRBPR associated with lightheadedness DISEASE but no CP/SOB. Also
complained of some lower abdominal cramping DISEASE discomfort that was
at worse [**5-3**] in severity and felt better after having a bowel
movement. Bleeding occurred in the setting of her bowel
movements. She had been on Aggrenox for an old CVA DISEASE but this was
held in the middle of [**Month (only) 958**] several days before her last
admission.
.
Patient has a history of LGIB DISEASE in [**2158**] found to have large AVM DISEASE
on c-scope DISEASE that was clipped. No subsequent scopes or bleeding DISEASE
until now.
.
In the ED initial vitals: 98.4 89 152/71 18 96% RA DISEASE . The Hct
was 36.5. On rectal exam by ED resident hemorrhoids were noted
and there was BRB in the vault but no active source seen. GI was
consulted. Three PIVs (two 16g and one 18g)were placed and the
patient was typed and crossed by blood bank for 4 units PRBCs.
.
On arrival in MICU she had no complaints and appeared fairly
stable. On further ROS at time of admission she denied chest
pains dyspnea DISEASE fevers/chills nusea vomiting diarrhea DISEASE .

Past Medical History:
Celiac Disease DISEASE
CVA / Right thalamic capsular stroke with resultant left sided
Ataxic hemiparesis DISEASE [**8-26**]
HTN DISEASE
Glaucoma DISEASE L eye
Hypothyroidism DISEASE
Hyperlipidemia DISEASE
Restless DISEASE legs
OA DISEASE
Diverticulitis DISEASE
Fe-deficiency anemia DISEASE
Osteoporosis DISEASE
Borderline pulm HTN DISEASE
LGIB DISEASE in [**2158**] found to have large AVM DISEASE in the cecum on c-scope DISEASE
that was clipped


Social History:
Lives in [**Location (un) 5481**] retirement facility. She is a widow and
has one son who lives close by and is very involved with her
care. Denies alcohol drugs or smoking. Extremely independent
at baseline with her ADLs IADLs prior to this admission.


Family History:
No known h/o CA blood disorders GI disorder DISEASE

Physical Exam:
PHYSICAL EXAM DISEASE ON ADMISSION TO MICU :
VS T 96.1F HR 85 BP 130/65 RR 17 Oxygen saturation 94% on
room air
Gen: Elderly female in NAD pleasant & conversant
HEENT: PERRL anicteric MMM
Heart: s1s2 RRR
Pulm: Scattered rhonchi
Abd: Admission Date: [**2147-6-24**] Discharge Date: [**2147-7-1**]


Service: ICU

HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old
female admitted with mental status changes. She is an elderly
woman who was institutionalized at a nursing home for the
past two months with a history of Crohn's disease DISEASE who was
admitted with a Crohn's DISEASE flare and diarrhea DISEASE on [**2147-6-24**].
Additionally she was noted to be more lethargic then usual.

PAST MEDICAL HISTORY: Crohn's disease DISEASE hypertension DISEASE
diverticulitis osteoarthritis DISEASE palpable deep venous
thrombosis DISEASE urinary tract infection.

MEDICATIONS: Celexa folate Pentasa Ritalin Nadolol.

ALLERGIES: Penicillin.

FAMILY HISTORY: No history of IBD DISEASE .

SOCIAL HISTORY: Nursing home resident.

PHYSICAL EXAMINATION: Blood pressure 109/52. Chest clear to
auscultation. Abdomen guaiac negative diffusely firm
abdomen.

HOSPITAL COURSE: The patient is an 84 year-old woman with
inflammatory bowel disease DISEASE admitted with hypotension DISEASE
dehydration DISEASE acute renal failure DISEASE and urinary tract infection DISEASE .
The patient was treated aggressively for the above issues.
Specifically for sepsis DISEASE and Crohn's DISEASE flare. She continued to
have a low blood pressure during her hospital stay and was
put on blood pressure supporting medication. She was treated
on antibiotics for her sepsis DISEASE and she was treated with
Methylamine and Protonix for her Crohn's DISEASE flare. Despite
these efforts the patient continued to deteriorate clinically
and family meetings were held to keep the family aware of her
poor prognosis. On [**2147-7-1**] at 6:01 a.m. the patient
expired despite aggressive fluid and pressor support. Her
niece [**Name (NI) 1894**] [**Name (NI) 805**] was notified.

FINAL DIAGNOSES:
1. Crohn's flare.
2. Sepsis DISEASE .






[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1895**] M.D. [**MD Number(1) 1896**]

Dictated By:[**Last Name (NamePattern1) 1897**]

MEDQUIST36

D: [**2147-8-28**] 17:02
T: [**2147-9-5**] 06:59
JOB#: [**Job Number 1898**]
Admission Date: [**2175-1-29**] Discharge Date: [**2175-2-4**]

Date of Birth: [**2089-2-21**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
shortness of breath and chest pain DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
85 year old man with CAD chronic systolic CHF DISEASE EF40% HTN DISEASE HLD
CKD peripheral vascular disease DISEASE presents with shortness of
breath and chest pain DISEASE . Pt states that two days ago he developed
some CP pain and sob. He took ntg with resolution of CP however
the sob got progressively worse. He felt that he had a Admission Date: [**2100-7-16**] Discharge Date: [**2100-8-12**]


Service: NEUROLOGY

Allergies DISEASE :
Bactrim

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left sided weakness neglect and global aphasia DISEASE

Major Surgical or Invasive Procedure:
Endotracheal Intubation

History of Present Illness:
History obtained from speaking with the patient's family and
review of OMR.

Ms. [**Known lastname 5021**] is a 89 year-old right-handed [**Known lastname 595**] speaking woman
with past medical history significant for hypertension anemia DISEASE
hypothyroidism chronic renal insufficiency renal cell cancer DISEASE
s/p right nephrectomy and left frontal stroke DISEASE in [**2100-5-11**] with
no residual deficits who presents with left sided weakness
neglect and aphasia DISEASE . She was first found this morning at 1030hrs
on [**2100-7-16**] on the floor by her husband. It was unknown how
long she was down for.
At that time she was able to communicate and said she couldn't
hear or see well. She did say that she tripped and fell and that
was why she was on the floor. She was also confused when she was
foundAdmission Date: [**2123-4-6**] Discharge Date: [**2123-4-9**]

Date of Birth: [**2081-1-14**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
seizure DISEASE

Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
Patient is a 42 year-old male with past medical history
significant for alcoholism DISEASE and depression DISEASE . Patient presented to
ED earlier this evening complaining of having fell off of a pole
and fell backwards [**Location 5491**]in [**Location (un) 86**]. He had a scalp
laceration which was not initially able to be repaired due to
c-spine DISEASE precautions. The patient had a head CT which was
negative for any intracranial bleeds DISEASE . CT neck also negative for
any fractures DISEASE .

In the ED initial vs were: T P 88 BP 89/58 RR 14 and O2 sat
100% RA DISEASE . While in the ED the patient appeared anxious and
confused initially. ETOH level was 105 and the rest of
toxicology screen was negative.
.
In the ED he then had a witnessed apneic DISEASE episode and then went
unresponsive for a few seconds per ED resdient but he had a
palpable pulse and blood pressures remained stable. During this
episode he had dropping oxygen saturations (drop not recorded)
and he was clinching his jaw to the point where he chipped his
tooth. Patient then went into rapid bilateral upper extremity
myoclonic jerking DISEASE followed by partial proning of his arms
bilaterally. He was given Ativan 2mg IV x2 then 5mg IV Ativan
then 6mg IV Ativan followed by 7mg IV Ativan in ED.
.
Minutes later he developed SVT DISEASE to 200 range which appeared to be
atrial fibrillation DISEASE vs. flutter DISEASE per ED resident. He was
intubated rapidly and then cardioverted in the ED with good
response as HR returned to NSR with rate in 70-90 range.
.
EKG was significant for borderline long QRS at .122 as well.
Toxicology was called and suggested patient be given bicarbonate
fluid to cover for possible TCA overdose DISEASE given EKG findings.
While in ED he was given tetanus shot given new scalp
laceration 3L NS IVFs and then 3Amps bicarbonate were given in
D5. He also got 1g IV Dilantin load and he was placed on
Propofol and a Versed drip started after intubation.
.
On arrival to the MICU patient was intubated and sedated. He was
on AC mode with Tv 600 x RR 16 FiO2 40% and PEEP 5. HR was 90
BP 132/88 and patient was afebrile. He had dry dressings packed
over right sided head laceration DISEASE and he was in a c-spine DISEASE collar.



Past Medical History:
-alcoholism
-depression

Social History:
Unable to obtain as intubated sedated

Family History:
NC

Physical Exam:
Vitals: AC mode with Tv 600 x RR 16 FiO2 40% and PEEP 5.
saturations 100%. HR 90 BP 132/88 Temp 99.9 F.
General: sedated intubated pale skin very warm
HEENT: Sclera anicteric MMM oropharynx with some evidence of
dried blood over right buccal mucosa
Skin: pale skin scalp with right posterior laceration crusted
dry blood DISEASE over hair about 1Admission Date: [**2132-9-17**] Discharge Date: [**2132-9-26**]


Service: MEDICINE

Allergies DISEASE :
Histamine H2 Inhibitors / Codeine / Sulfa (Sulfonamide
Antibiotics) / Proton Pump Inhibitors / Penicillins / Demerol

Attending:[**First Name3 (LF) 3705 DISEASE **]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname 5501**] is a [**Age over 90 **] year-old woman with a history of
Parkinson's CAD dilated CM DISEASE (EF 30%) chronic mesenteric
ischemic s/p stents recent fall complicated by humeral
fracture DISEASE aspiration pneumonia DISEASE . Please see admission note for
full details of history. Briefly she was admitted to OSH [**9-9**]
with aspiration pneumonia DISEASE . She was treated with broad spectrum
antibiotics but decomepensated with [**Last Name (un) **] demand ischemia DISEASE
concern for new mesenteric ischemia DISEASE . She was transferred from
OSH ICU to [**Hospital1 18**] ICU on [**9-17**].
.
In the ICU she was hemodynamically stable without oxygen
requirement. Vancomycin and levofloxacin (needs 6 more days to
complete 10 day course) were started. PICC was placed.
Aspiration was thought to be in part secondary to compromised
mental status from polypharmacy. Zyprexa was given because
patient was moaning resulting in BP drop to the 80s. EKG showed
lateral TW changes thought to be secondary to demand. Plavix
was held.

Past Medical History:
* Cardiac Risk Factors: (-)Diabetes (Admission Date: [**2166-12-9**] Discharge Date: [**2166-12-12**]

Date of Birth: [**2094-11-9**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Loss of consciousness DISEASE

Major Surgical or Invasive Procedure:
Hemodialysis.
Intubation.


History of Present Illness:
72 year old man with stage 4 CKD DISEASE on HD DISEASE CAD HTN asthma DISEASE who
presented with multiple falls and was found by EMS to be in a
wide complex brady to 20 bpm with BP of 50 systolic. Per wife
and friend pt was in USOH until day prior to admission when he
started to feel shaky & tremulous DISEASE hands. Gait somewhat unsteady
w/ generalized weakness. Has not had any fevers/chills/sweats
no diarrhea DISEASE no CP/palpitations/SOB.
On morning of admission pt went shopping w/friend upon leaving
store pt was very nauseated Admission Date: [**2169-8-9**] Discharge Date: [**2169-8-12**]

Date of Birth: [**2094-11-9**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Bradycardia DISEASE (slow heart rate)

Major Surgical or Invasive Procedure:
Implantation of a Pacemaker ([**Company 1543**] VDD type single lead)


History of Present Illness:
Mr. [**Known firstname 1975**] [**Known lastname 5512**] is a 74 yo [**Known lastname 595**]-speaking male with ESRD DISEASE
on HD DISEASE h/o mild CAD hypertension dyslipidemia DISEASE diastolic
dysfunction who presented to hemodialysis today and was found
to be bradycardic. He completed hemodialysis without any
complications and had 2.5L of fluid removed. He had a heart
rate of Admission Date: [**2169-12-31**] Discharge Date: [**2170-1-5**]

Date of Birth: [**2094-11-9**] Sex: M

Service: [**Year (4 digits) 662**]

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Femoral line placed

History of Present Illness:
75 y/o M [**First Name3 (LF) **] speaking only PMH ESRD DISEASE on HD DISEASE CAD PAF COPD DISEASE
HTN DISEASE who presensts with altered mental status of 2 days duration.
Initially felt to be secondary to percocet use at rehab but HD
facility was concerned and sent patient to be evaluated. Per
family patient is AOx3 at baseline but has been more confused
recently. Notes slow decline over several days since being at
the rehab. States he was also given a Admission Date: [**2114-6-14**] Discharge Date: [**2114-6-20**]

Date of Birth: [**2041-10-5**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
incontinence/lower extremity pain/weakness DISEASE

Major Surgical or Invasive Procedure:
Posterior cervical laminectomy
Decompressive lumbar laminectomy


History of Present Illness:
72-year-old woman who has a history of mild
mental retardation who lives and works in a monitored care
setting. She has a complex past medical history including a
distant left frontal meningioma DISEASE resection as well as a previous
anterior cervical discectomy with fusion in [**2107**] by Dr. [**Last Name (STitle) 1338**]
( C4-C7 DISEASE ). The patient is unable to recall the majority of her
past medical history. She now presents with progressive urinary
incontinence DISEASE and fecal incontinence DISEASE . Urinary incontinence was
noticed for at least a year. Fecal incontinence DISEASE seems to be
present for about 3-4 weeks only. The patient has in addition
felt a decrease in her ability to walk but is mobile with a
walker. She complains about bilateral lower extremity
paresthesias DISEASE left greater than right. She has intermittent
bilateral upper extremity numbness DISEASE . She also complains about
progressive right-sided thigh pain DISEASE when she is going down the
stairs. She walks with a
walker. The patient takes home medications including
hydrochlorothiazide Protonix Fosamax and naproxen. She is
not
known to have any drug allergies DISEASE . She is a nonsmoker
nondrinker.


Past Medical History:
The patient has a past medical history that is relevant
for hypertension DISEASE GERD osteoporosis DISEASE . Surgical history remains
relevant for a distant left frontal meningioma DISEASE resection status
post ACDF C4-C7 DISEASE in [**2107**] and a right-sided THR.

Social History:
The patient takes home medications including
hydrochlorothiazide Protonix Fosamax and naproxen. She is
not
known to have any drug allergies DISEASE . She is a nonsmoker
nondrinker.

Family History:
noncontributory

Physical Exam:
Physical examination reveals that she is awake and alert and
interactive. She is slightly retarded and slow but pleasantly
interactive. She walks into the office with a walker. She has
an obvious kyphosis DISEASE but is more mobile with a walker and shows
no signs of imbalance. The cranial nerves are remarkable for a
prominent right-sided exotropia at rest. Bilateral pupils are
reactive to light and accommodation. Extraocular movements DISEASE are
full despite disconjugate gaze. There is no nystagmus DISEASE . She has
good visual fields. Facial strength and sensation are normal.
Hearing is intact. Tongue is midline and shows no signs of
atrophy DISEASE of fasciculation DISEASE . Motor exam is somewhat limited but
shows mild to moderate wasting DISEASE of hand intrinsic muscles as well
as thenar. Tone is increased in both legs with signs of
spasticity DISEASE . She has weakness DISEASE in the distal upper extremity
approximately [**5-2**] bilaterally. She has good strength
approximately bilaterally except the right-sided deltoid. She
has bilateral lower extremity weakness DISEASE 4/5 with more prominent
weakness in the toe bilaterally. Fine motor control is not
testable. She has no drift. Sensory exam reveals no obvious
deficits bilaterally. She complains about dysesthesias DISEASE in a
nonradicular pattern. Symmetric reflexes were elicited. She
has
bilateral upgoing toes.


Pertinent Results:
[**2114-6-14**] 08:30PM WBC-12.5* RBC-3.29* HGB-10.3* HCT-29.1*
MCV-88 MCH-31.3 MCHC-35.4* RDW-14.1
[**2114-6-14**] 08:30PM PLT COUNT-224
[**2114-6-14**] 08:00PM CK(CPK)-136
[**2114-6-14**] 08:00PM CK-MB-9 DISEASE cTropnT-Admission Date: [**2186-1-13**] Discharge Date: [**2186-1-20**]

Date of Birth: [**2126-12-12**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Acute Renal Failure DISEASE

Major Surgical or Invasive Procedure:
HD DISEASE line placement

History of Present Illness:
59 y/o M w/ h/o hepatitis C HTN CKD DISEASE with baseline Cr of 2.0.
Patient had been having 2 weeks of fatigue fever chills DISEASE
dysuria DISEASE with watery stools DISEASE and decreased PO intake. Had been
essentially bed bound. By Sunday was able to get out of bed and
on Tuesday visited his PCP who found to have Cr of 20 and BUN of
120. Was brought in for repeat labs which confirmed initial
findings and then referred to ED for evaluation.
.
In the ED initial vs were: T98.8 P83 BP 161/102 R 18 O2 sat 93%
RA DISEASE . SBP of 220/125 at maximum during ED stay. Exam notable for
diminished breath sounds. LUQ TTP DISEASE on exam. Asterixis and coarse
tremor DISEASE on exam. CXR - LLL infiltrate with mild to moderate
congestion. Treated with lasix as per Renal with 250cc urine
output. Azithromycin/CTX for pneumonia DISEASE . Renal planned to
continue diuresis and consider HD. Vitals on transfer HR 84 BP
180/100 RR 21 O295% 2L.
.
On arrival patient was c/o mild LUQ pain DISEASE that had been present
for some time.
.
Review of sytems:
(Admission Date: [**2118-2-6**] Discharge Date: [**2118-2-16**]

Date of Birth: Sex:

Service:

CHIEF COMPLAINT: Initially admitted for complaints of
shortness of breath DISEASE .

HISTORY OF PRESENT ILLNESS: This is a 72 year old female
with a history of chronic obstructive pulmonary disease DISEASE
hypertension DISEASE hyperlipidemiaAdmission Date: [**2102-2-19**] Discharge Date: [**2102-3-9**]


Service: Neurosurgery

HISTORY OF PRESENT ILLNESS: This is a 79-year-old female
with a history of atrial fibrillation DISEASE on Coumadin
hypertension DISEASE and cerebellar cerebrovascular accident DISEASE who
presented to the Emergency Department complaining of nausea DISEASE
no vomiting DISEASE and headache DISEASE since one night prior to admission.
When the patient woke up this morning the patient had
progressive dysarthria DISEASE . The patient denied any visual or
auditory changes. The patient also denied any fevers DISEASE
chills DISEASE changes in bowel habits chest pain shortness DISEASE of
breath melena DISEASE bright red blood per rectum and hematemesis DISEASE .

PAST MEDICAL HISTORY: 1. Hypertension DISEASE . 2. Atrial
fibrillation DISEASE . 3. Cerebrovascular accident DISEASE .

MEDICATIONS AT HOME: 1. Atenolol. 2. Coumadin. 3. Plendil.
4. Lipitor. 5. Avapro. 6. Neurontin. 7. Hydralazine.

ALLERGIES: 1. Codeine. 2. Macrodantin.

PHYSICAL EXAMINATION: The patient's temperature was 96.8
pulse 71 blood pressure 206/110 respiratory rate 16 oxygen
saturation was 94% on room air. The patient was alert and
oriented x 3 in no acute distress. The patient's speech was
dysarthric. The patient's pupils were equal round and
reactive to light. The patient's extraocular movements DISEASE were
intact. The patient had symmetric eyebrow lift and
symmetric smile. The patient had no tongue deviation no
pronator drift. The patient had 5Admission Date: [**2119-6-14**] Discharge Date: [**2119-7-1**]

Date of Birth: [**2045-3-23**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Percocet

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
cholecystitis DISEASE

Major Surgical or Invasive Procedure:
Intubation
Cholecystomy Tube placement
Thoracentesis


History of Present Illness:
74 y/o female with PMH significant for COPD DISEASE CAD and
hypertension DISEASE admitted to [**Hospital1 18**] on [**6-14**] to the surgery service
with two days of epigastric and right upper quadrant pain DISEASE . She
had also been febrile DISEASE to 101 and had one episode of nausea DISEASE and
vomiting DISEASE . Per notes her abdominal exam was significant for
epitastric and right upper quadrant tendernessAdmission Date: [**2121-5-30**] Discharge Date: [**2121-7-5**]

Date of Birth: [**2055-7-11**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Small bowel obstruction DISEASE

Major Surgical or Invasive Procedure:
ex lap bowel resection [**Doctor Last Name **] ostomy ([**5-30**]) percutaneous
tracheotomy CT guided drainage with catheter placement to
abdominal fluid collection left sided thoracostomy
bronchoscopy central line placement

History of Present Illness:
65 y/o F s/p total gastrectomy for signet ring cell gastric
adenocarcinoma DISEASE with Roux-en-Y esophagojejunostomy and feeding
jejunostomy tube placement presented on POD #10 with acute onset
of RUQ pain DISEASE . Patient had recent swallow study showing no
evidence of a leak and had been tolerating a clear liquid/full
liquid diet until presenting to the hospital on [**5-30**]. Patient
also complained of nausea vomiting fevers DISEASE and chills DISEASE . She had
her last bowel movement DISEASE on the morning of admission.

Past Medical History:
Breast CA s/p hysterectomy and Chemo (adriamycin and tamoxifen)
GERD
Hypercholesterolemia DISEASE
Glaucoma DISEASE

Physical Exam:
CV: asystole DISEASE no heart rhythm
Resp: no breath sounds no respirations - spontaneous or
otherwise
Neuro: pupils dilated to 5mm unreactive to light bilaterallyAdmission Date: [**2111-7-28**] Discharge Date: [**2111-8-11**]

Date of Birth: [**2035-7-3**] Sex: M

Service: SURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Vomiting DISEASE and abdominal pain/distention

Major Surgical or Invasive Procedure:
[**2111-7-30**]- Sigmoid colectomy
[**2111-8-4**]- Exploratory Laparotomy Resection of Anastamosis
Hartmann's Closure with descending end colostomy
[**2111-8-7**]- Right upper extremity PICC line placement


History of Present Illness:
Mr. [**Known lastname 5549**] is a 76 year old male with a history of CHF HTN DISEASE
and [**Hospital 5550**] transferred to [**Hospital1 18**] from [**Hospital 100**] Rehab on [**2111-7-28**] with
4 days of worsening abdominal distention DISEASE and feculent vomiting DISEASE .
He reportedly had not had a bowel movement or passed gas since
[**2111-7-24**]. While being transported to the hospital he reportedly
had a low oxygen saturation to 80%. He denied fever chills DISEASE
SOB or CP. In the ED imaging was concerning for large bowel
volvulus DISEASE and the patient was admitted to the CSICU under the
acute care service for episodes of desaturation DISEASE and further
workup of his abdominal symptoms.

Past Medical History:
-Congestive Heart Failure
-Hypertension
-Migraines
-s/p right hip replacement
-Chronic constipation DISEASE
-Cataracts
-BPH
-Depression/Anxiety
-s/p hernia DISEASE repair

Social History:
Resident at [**Hospital 100**] Rehab

Family History:
noncontributory

Physical Exam:
Vitals: HR95 BP158/103 RR16 93% on 5L
GEN: A&Ox3 NAD
HEENT: No scleral icterus oral mucous membranes dry
CV: RR nl S1/S2 No M/G/R
PULM: Clear to auscultation b/l No W/R/R
ABD: Grossly distended tympanic nontender no rebound or
guarding Admission Date: [**2148-5-19**] Discharge Date: [**2148-5-28**]

Date of Birth: [**2075-9-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Maroon stools

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Full hx as per ICU admit note. Briefly this is a 72 year old
man with a past medical history significant for metastatic
gastric cancer DISEASE (tolerating adriamycin after failing multiple
regimens) localized prostate cancer DISEASE bilateral cephalic vein
thromboses DISEASE in the setting of coumadin therapy in [**2148-4-9**] and
portacath thrombus DISEASE in [**2148-1-11**] who presented with four days
of dark stools and hematocrit drop from 37 to 24 and
intermittent abdominal pain DISEASE and nausea DISEASE after being discharged
to nursing facility on [**5-13**] on chronic lovenox therapy.
.
In the ICU the pt underwent an EGD with showed a fungating mass
with stigmata of recent bleeding DISEASE of malignant appearance was
found in the antrum of the stomach. There was an ulcer DISEASE within
the mass with an adherent clot. The ulcer DISEASE was injected.
However after the procedure the patient continued to have
bleeding DISEASE and an angiography was performed. The GDA was embolized
with coils and Gelfoam slurry. Subsequently the patient has been
doing well and no more drop in the hct was noted. He was
transfused a total of 4 U PRBC per the blood bank record the
last one on [**5-20**].
.
The patient is currently doing well and denies any further
abdominal pain DISEASE or nausea/vomiting DISEASE . He reports 2 cream-colored BM
today.
.
ROS: Otherwise negative for dysuria CP SOB DISEASE . He has been able
to tolerate liquids and solid food. He endorses a weight loss DISEASE of
144 to 126 pounds in the last 2 months.


Past Medical History:
-Gastric cancer DISEASE diagnosed in [**2147-7-11**]Admission Date: [**2130-5-11**] Discharge Date: [**2130-6-2**]

Date of Birth: [**2057-7-28**] Sex: F

Service: SURGERY

Allergies DISEASE :
Penicillins / Interferons / Latex

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Altered mental status and hypotension/Pneumonia

Major Surgical or Invasive Procedure:
[**2130-5-15**]: Paracentesis
[**2130-5-16**]: Orthotopic Liver transplant
[**2130-5-23**]: Post pyloric feeding tube placement
[**2130-5-23**]: Flexible Bronchoscopy
[**2130-5-24**]: Pleural tapAdmission Date: [**2142-8-26**] Discharge Date: [**2142-8-31**]

Date of Birth: [**2068-12-5**] Sex: M

Service: MICU-GREEN

HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
male with a recent history of paroxysmal atrial fibrillation DISEASE
and hypercholesterolemia DISEASE who presented to the Emergency
Department with the chief complaint of syncope DISEASE . The patient
was discharged from [**Hospital1 69**] with
the diagnosis of pulmonary embolism DISEASE about six months prior to
the current admission and was started on Warfarin. One month
prior to this admission the patient reports not feeling well
with worsening gastric distress DISEASE . A few weeks prior to
admission he fell down on his back and started taking
ibuprofen 1000 mg once a day for pain DISEASE and Vioxx in addition
to his aspirin and Coumadin regimen.

The night prior to admission he was found by his wife on the
bathroom floor in a pool of urine unresponsive without any
body movements post-ictal state. EMS was activated
however the patient refused to go to the hospital. A
similar episode happened at 2 a.m. the same night and at
07:45 on the day of admission the patient lost consciousness
once again when he was trying to sit up. He was then
transferred to [**Hospital1 69**].

The patient reports some nausea DISEASE and epigastric pressure which
is post-prandial. He denies any emesis melena diarrhea DISEASE or
constipation DISEASE . He describes the room spinning with attempts
to sit upright. No history of previous episodes was noted.
Denies incontinence DISEASE . He does have diaphoresis DISEASE and weakness DISEASE
with orthostatic DISEASE changes.

In the Emergency Department stool guaiac was trace positive.
Hematocrit was 24.8 with a baseline of 46. Gastric lavage
was grossly positive for coffee ground material. His INR was
found to be 4.4. He was given Vitamin K 10 mg
subcutaneously 2.5 liters of normal saline two units of
packed red blood cells and two units of fresh frozen plasma
and transferred to the Medical Intensive Care Unit for
further management.

PAST MEDICAL HISTORY:
1. Hyperthyroid disease DISEASE status post radioactive iodine
ablation now hypothyroid DISEASE on Levoxyl.
2. History of pulmonary embolism DISEASE etiology unknown. It was
thought to be induced by frequent flying to [**State 108**]. The
patient was started on Coumadin five months prior to this
admission.
3. Hypercholesterolemia. Well controlled on Lipitor. Last
total cholesterol was 168 in [**2142-5-28**].
4. Paroxysmal atrial fibrillation DISEASE in the setting of
pulmonary embolism DISEASE .

PAST SURGICAL HISTORY:
1. Only significant for a right inguinal hernia DISEASE repair.

ALLERGIES: Penicillin.

OUTPATIENT MEDICATIONS:
1. Lipitor 10 mg three times a week.
2. Aspirin 81.
3. Propranolol 10 mg three times a day.
4. Coumadin 6.25 mg once a day.
5. Levoxyl 100 mEq q. day.
6. Ambien p.r.n.
7. Vitamins.
8. Vioxx times three weeks.

SOCIAL HISTORY: The patient quit smoking 20 years agoAdmission Date: [**2142-8-26**] Discharge Date: [**2142-8-31**]

Date of Birth: [**2068-12-5**] Sex: M

Service: MICU-GREEN

HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
male with a recent history of paroxysmal atrial fibrillation DISEASE
and hypercholesterolemia DISEASE who presented to the Emergency
Department with the chief complaint of syncope DISEASE . The patient
was discharged from [**Hospital1 69**] with
the diagnosis of pulmonary embolism DISEASE about six months prior to
the current admission and was started on Warfarin. One month
prior to this admission the patient reports not feeling well
with worsening gastric distress DISEASE . A few weeks prior to
admission he fell down on his back and started taking
ibuprofen 1000 mg once a day for pain DISEASE and Vioxx in addition
to his aspirin and Coumadin regimen.

The night prior to admission he was found by his wife on the
bathroom floor in a pool of urine unresponsive without any
body movements post-ictal state. EMS was activated
however the patient refused to go to the hospital. A
similar episode happened at 2 a.m. the same night and at
07:45 on the day of admission the patient lost consciousness
once again when he was trying to sit up. He was then
transferred to [**Hospital1 69**].

The patient reports some nausea DISEASE and epigastric pressure which
is post-prandial. He denies any emesis melena diarrhea DISEASE or
constipation DISEASE . He describes the room spinning with attempts
to sit upright. No history of previous episodes was noted.
Denies incontinence DISEASE . He does have diaphoresis DISEASE and weakness DISEASE
with orthostatic DISEASE changes.

In the Emergency Department stool guaiac was trace positive.
Hematocrit was 24.8 with a baseline of 46. Gastric lavage
was grossly positive for coffee ground material. His INR was
found to be 4.4. He was given Vitamin K 10 mg
subcutaneously 2.5 liters of normal saline two units of
packed red blood cells and two units of fresh frozen plasma
and transferred to the Medical Intensive Care Unit for
further management.

PAST MEDICAL HISTORY:
1. Hyperthyroid disease DISEASE status post radioactive iodine
ablation now hypothyroid DISEASE on Levoxyl.
2. History of pulmonary embolism DISEASE etiology unknown. It was
thought to be induced by frequent flying to [**State 108**]. The
patient was started on Coumadin five months prior to this
admission.
3. Hypercholesterolemia. Well controlled on Lipitor. Last
total cholesterol was 168 in [**2142-5-28**].
4. Paroxysmal atrial fibrillation DISEASE in the setting of
pulmonary embolism DISEASE .

PAST SURGICAL HISTORY:
1. Only significant for a right inguinal hernia DISEASE repair.

ALLERGIES: Penicillin.

OUTPATIENT MEDICATIONS:
1. Lipitor 10 mg three times a week.
2. Aspirin 81.
3. Propranolol 10 mg three times a day.
4. Coumadin 6.25 mg once a day.
5. Levoxyl 100 mEq q. day.
6. Ambien p.r.n.
7. Vitamins.
8. Vioxx times three weeks.

SOCIAL HISTORY: The patient quit smoking 20 years agoAdmission Date: [**2156-9-14**] Discharge Date: [**2156-10-4**]

Date of Birth: [**2116-3-20**] Sex: F

Service: NEUROLOGY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
confusion DISEASE

Major Surgical or Invasive Procedure:
Dialysis on [**2156-9-14**] for acidosis DISEASE and hypokalemia DISEASE
Intubation
PICC line placement

History of Present Illness:
40-year-old female DM2 DISEASE transferred from [**Hospital 1562**] Hospital for
severe acidosis DISEASE from Admission Date: [**2113-6-4**] Discharge Date: [**2113-6-10**]

Date of Birth: [**2055-3-17**] Sex: M


HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
a 5-year history of a large right lobe cavernous hemangioma.
He was admitted to [**Hospital1 69**] on
[**5-31**] after experiencing the subacute onset of fevers DISEASE
time to have had a intrahepatic mass bleed DISEASE requiring 2 units
of packed red blood cells. He stabilized and sent home for
the weekend with plans to come back on [**6-4**] to undergo the
resection of this hemangioma DISEASE which had now become unstable.

PAST MEDICAL HISTORY: Past medical history significant for
hypercholesterolemia DISEASE which has since resolved.
MEDICATIONS ON ADMISSION: None.

ALLERGIES: No known drug allergies DISEASE .

PHYSICAL EXAMINATION ON PRESENTATION: Examination at the
time of admission revealed his lungs were clear to
auscultation bilaterally. His heart had a regular rate and
rhythm. His abdomen was soft nontender and nondistended.
His extremities were warm and well perfused.

HOSPITAL COURSE: The patient was admitted to the General
Surgical Service on [**2113-6-4**]. Initial laboratory values
at that time demonstrated a hematocrit of 34.2 an alkaline
phosphatase of 559 and a total bilirubin of 2. The rest of
his laboratories were unremarkable.

On [**6-5**] the patient underwent an uncomplicated resection
of the hemangioma DISEASE of his right hepatic lobe with minimal
resection of the liver parenchyma itself. The patient
tolerated the procedure well.

Overnight the patient was recovered in the Surgical
Intensive Care Unit predominantly because of a 5.5-liter
blood loss DISEASE intraoperative. He remained intubated until
postoperative day one at which time he was extubated without
difficulty.

He was transferred to the floor on postoperative day one and
had an uneventful postoperative course thereafter. He
continued to have low-grade fevers DISEASE postoperatively but by
the day of discharge had remained afebrile for greater than
24 hours.

On postoperative day four the patient passed flatus and had
a bowel movement and his diet was advanced without
difficulty. His urine output had remained more than adequate
throughout his hospital stay. The Foley catheter was
discontinued on postoperative day three. His total bilirubin
rose to 8 on the day of operation but continued to trend
downward to 2 on postoperative day four. His hematocrit had
dropped to 29 postoperatively after resuscitation and blood
products. On the day of discharge his hematocrit has
stabilized at around 27. The pathology on the specimen was
positive only for hemangioma DISEASE with areas of infarct DISEASE . He had a
blood culture from [**6-6**] that grew out 1/4 bottles positive
for guaiac-negative StaphylococcusAdmission Date: [**2123-10-27**] Discharge Date:

Date of Birth: [**2085-3-7**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: This is a 38-year-old man with
AIDS DISEASE referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4569**] who has fevers DISEASE to greater
than 104 likely pneumonia DISEASE or other pulmonary process
increasing for one month. He reports increased cough DISEASE
usually nonproductive but occasional production of bloody
sputum. In addition he has some dark stool which he states
is maroon in color in the last few weeks as well as nausea DISEASE
and vomiting DISEASE . He states that sometimes he vomits DISEASE blood.
Reports left upper quadrant pain DISEASE times one month with eating.
Denies dyspnea DISEASE or chest pain DISEASE . He states some pain DISEASE in his
chest with cough DISEASE only and that's resolved mild headache DISEASE like
a hot plate on his forehead mild neck pain DISEASE positive urinary
frequency and dysuria DISEASE times weeks. Today he has had
diarrhea DISEASE 30 minutes after meals. He states he has been
depressed DISEASE not sleeping and wants to die without active
suicidal ideation DISEASE .

PAST MEDICAL HISTORY:
1. HIV diagnosed in [**2118**] treated with HAART in [**2122-7-2**]
viral load was 50000 went to less than 50 but then patient
quit his medications after his rectal abscess. Last CD4
count [**2123-7-2**] was 1 viral load in [**2123-6-1**] was greater
than 500000.
2. Kaposi's of skin oral cavity and lung status post
chemotherapy in [**2119**].
3. ......... of the skin buttocks in [**2122-4-1**].
4. History of neutropenia DISEASE exacerbated by Bactrim and
resolved with discontinuation.
5. HSV2 resolved [**2123-6-1**] perianal.
6. History of perianal abscess DISEASE in [**2122**] status post surgery.
7. Left upper lobe pneumonia in [**2123-7-10**] treated with
levofloxacin and resolved.
8. Recurrent zoster DISEASE .
9. Pancreatitis DISEASE .
10. Oral ulcers DISEASE and [**Female First Name (un) **] esophagitis DISEASE .
11. Depression DISEASE .
12. Tinea DISEASE barba.

SOCIAL HISTORY: 45 pack year of tobacco. Formerly 12-24
beers most recently until five days ago.

FAMILY HISTORY: Noncontributory.

ALLERGIES: Bactrim intolerance.

MEDICATIONS: Patient on only one month in [**Month (only) 205**] acyclovir 800
t.i.d. times 30 days then b.i.d. azithromycin 250 times
five q. week dapsone 100 q.d. Epivir 150 b.i.d. Indinavir
400 b.i.d. Paxil 20 Prilosec 20 Ritonavir 100 times four
b.i.d. stavudine 40 b.i.d.

REVIEW OF SYSTEMS: No rigors fevers DISEASE and chills DISEASE and sweats DISEASE
today only. Weight loss DISEASE 30 pounds in one month. Cough.
Bloody sputum. Very weak appetite is poor severe watery DISEASE
diarrhea DISEASE (Admission Date: [**2112-4-22**] Discharge Date: [**2112-5-5**]

Date of Birth: [**2035-10-21**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 134**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
76yo F with PAF s/p recent TEE-DCCV on [**4-21**] HTN DISEASE admitted with
hypoxic respiratory failure DISEASE . She was recently hospitalized from
[**Date range (1) 1919**] for a supratherapeutic INR of 16. She was in AF with
a ventricular rate of 110s-140s asymptomatic. Medical
management of her AF was initially tried. She was maintained on
her atenolol and propafenone and diltiazem was added. The
decision was then made to pursue cardioversion instead.
TEE-DCCV was performed on [**2112-4-21**]. She was in sinus rhythm
after the procedure and had a HR in the 50s on atenolol and
propafenone upon discharge. The diltiazem had been discontinued
secondary to bradycardia DISEASE post-procedure. She was also
discharged on Coumadin 1mg qhs. Her family states her symptoms
began just prior to discharge when she began to feel short of
breath and fatigued. Her symptoms progressively worsened at
home. She was seen in [**Company 191**] the next morning and was found to
have O2 sats in the 80s so she was sent to the ED.
.
In the ED her T was 100.6 HR 70s in NSR DISEASE and she was 84% on
4L. Her CXR showed bilateral pleural effusions DISEASE and vascular
engorgement and her INR was 9. She received a Combivent neb
Lasix 20mg IV levofloxacin 500mg IV and vitamin K 5mg SC. She
was intubated for hypoxia DISEASE . Repeat CXR showed improvement in
pulmonary edema DISEASE after Lasix. She was admitted to the CCU for
further management of hypoxia DISEASE due to possible CHF DISEASE .

Past Medical History:
1. Atrial fibrillation DISEASE : diagnosed [**2102**] on propafenone x several
years started Coumadin [**4-11**] s/p TEE-DCCV on [**4-21**]
2. Hypertension DISEASE : on enalapril and atenolol

Social History:
No EtOH no past or present smoking hx no illicit drug use.
Lives with her husband in [**Name (NI) 86**] has 1 daughter. Used to work
in [**Country 532**] as an engineer. Moved to US from [**Country 532**] in [**2098**].

Family History:
Noncontributory.

Physical Exam:
vitals- T 98.7 HR 57 RR 13 BP 118/55 O2sat 100%
vent- AC 450/14 PEEP 5 FiO2 100%
General- sedated and intubated
HEENT- PERRL ETT
Neck- JVP 9cm
Lungs- diffuse rhonchi decreased breath sounds bilaterally
Heart- RRR normal S1/S2 no murmur/rub/gallop
Abd- soft NT ND NABS
Ext- 2Admission Date: [**2123-10-27**] Discharge Date:

Date of Birth: [**2085-3-7**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: This is a 38-year-old man with
AIDS DISEASE referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4569**] who has fevers DISEASE to greater
than 104 likely pneumonia DISEASE or other pulmonary process
increasing for one month. He reports increased cough DISEASE
usually nonproductive but occasional production of bloody
sputum. In addition he has some dark stool which he states
is maroon in color in the last few weeks as well as nausea DISEASE
and vomiting DISEASE . He states that sometimes he vomits DISEASE blood.
Reports left upper quadrant pain DISEASE times one month with eating.
Denies dyspnea DISEASE or chest pain DISEASE . He states some pain DISEASE in his
chest with cough DISEASE only and that's resolved mild headache DISEASE like
a hot plate on his forehead mild neck pain DISEASE positive urinary
frequency and dysuria DISEASE times weeks. Today he has had
diarrhea DISEASE 30 minutes after meals. He states he has been
depressed DISEASE not sleeping and wants to die without active
suicidal ideation DISEASE .

PAST MEDICAL HISTORY:
1. HIV diagnosed in [**2118**] treated with HAART in [**2122-7-2**]
viral load was 50000 went to less than 50 but then patient
quit his medications after his rectal abscess. Last CD4
count [**2123-7-2**] was 1 viral load in [**2123-6-1**] was greater
than 500000.
2. Kaposi's of skin oral cavity and lung status post
chemotherapy in [**2119**].
3. ......... of the skin buttocks in [**2122-4-1**].
4. History of neutropenia DISEASE exacerbated by Bactrim and
resolved with discontinuation.
5. HSV2 resolved [**2123-6-1**] perianal.
6. History of perianal abscess DISEASE in [**2122**] status post surgery.
7. Left upper lobe pneumonia in [**2123-7-10**] treated with
levofloxacin and resolved.
8. Recurrent zoster DISEASE .
9. Pancreatitis DISEASE .
10. Oral ulcers DISEASE and [**Female First Name (un) **] esophagitis DISEASE .
11. Depression DISEASE .
12. Tinea DISEASE barba.

SOCIAL HISTORY: 45 pack year of tobacco. Formerly 12-24
beers most recently until five days ago.

FAMILY HISTORY: Noncontributory.

ALLERGIES: Bactrim intolerance.

MEDICATIONS: Patient on only one month in [**Month (only) 205**] acyclovir 800
t.i.d. times 30 days then b.i.d. azithromycin 250 times
five q. week dapsone 100 q.d. Epivir 150 b.i.d. Indinavir
400 b.i.d. Paxil 20 Prilosec 20 Ritonavir 100 times four
b.i.d. stavudine 40 b.i.d.

REVIEW OF SYSTEMS: No rigors fevers DISEASE and chills DISEASE and sweats DISEASE
today only. Weight loss DISEASE 30 pounds in one month. Cough.
Bloody sputum. Very weak appetite is poor severe watery DISEASE
diarrhea DISEASE (Admission Date: [**2123-12-31**] Discharge Date: [**2124-1-10**]

Date of Birth: [**2085-3-7**] Sex: M

Service: Medicine

ADDENDUM: The patient is a 38 year old [**Country 4574**] male with
AIDS DISEASE left upper lobe aspergilloma and lower extremity
paraparesis DISEASE who was originally admitted on [**2123-10-26**] with fever DISEASE and cough DISEASE . He was subsequently found to have
an left upper lobe aspergilloma DISEASE which was initially treated
with amphotericin which led to the patient having seizures DISEASE .
He was then placed in a phenobarbital coma which slowly
resolved and was started on itraconazole therapy. Please
refer to the dictation summary dictated on [**2124-1-5**]
dictated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].

1. Neurologic: On [**2123-12-29**] the patient began
complaining of dizziness DISEASE . He did not describe a room
spinning sensation. He felt like his head was falling to the
side but no particular side consistently. He did not
complain of new numbness weakness DISEASE or tingling. He did not
complain of dysphagia dysarthria DISEASE hearing changes sense of
fullness DISEASE in the ear or headache DISEASE . He had no focal deficits on
examination.

The patient was started on Meclizine and initially showed
improvement on that. Approximately one week after the
Meclizine was started the patient was changed to a lower
dose of Meclizine. After that change the patient began
experiencing dizziness DISEASE again. Subsequently neurology was
consulted on hospital day number 75. Neurology felt that the
patient's dizziness DISEASE was likely multi-factorial. The cause
was believed to be vestibular peripheral superimposed axial
and lower extremity weakness DISEASE with prolonged immobility.

Additionally multiple medications that the patient was
taking have been associated with dizziness DISEASE including the
patient's seizure DISEASE medications. Neurology recommended
checking a phenobarbital level. On [**2124-1-9**] the
level was 23 which was in the therapeutic range. Neurology
also recommended considering a magnetic resonance imaging
scan if the patient's dizziness DISEASE did not resolve or worsened.
Additionally they recommended discontinuing Reglan if the
patient's symptoms did not resolve and the Reglan was not
deemed necessary. The patient did not have any further
seizures DISEASE during this hospitalization.

2. Infectious disease: The issue of reverse transcript ACE
inhibitors was revisited within the last two weeks. The case
was discussed with infectious disease DISEASE who have been
following the case. At this time they recommended holding
on adding reverse transcript ACE inhibitors. The patient's
amylase level on [**2124-1-7**] was 306. When the amylase
level returns to normal the infectious disease DISEASE service will
revisit the issue of reverse transcript ACE inhibitors.

The patient was started on protease inhibitors on [**2123-12-26**]. According to fetal distress the patient may stay
on double protease inhibitor therapy for up to three months
before resistance occurs. The plan is to revisit the issue
of reverse transcript ACE inhibitors once the patient's
amylase level is within normal limits.

On hospital day number 73 the patient developed a 1 to 2 cm
ulcer DISEASE at the perineum. It was mildly tender to palpation.
The patient was started on acyclovir. This also was presumed
to be due to herpes simplex virus type II DISEASE .

3. Physical therapy and occupational therapy: The patient
continued to improve over the course of the hospitalization.
On discharge the patient was able to ambulate approximately
200 feet with a standard walker. The patient's lower
extremity strength was continuing to improve each day. The
patient was also able to climb several stairs.

DISPOSITION: The patient will need to follow up with the
Infectious Disease DISEASE Clinic in two to three weeks after
discharge (telephone number [**Telephone/Fax (1) 457**]).

DISCHARGE MEDICATIONS:
Acyclovir 800 mg p.o.t.i.d.
Amprenavir 450 mg p.o.b.i.d.
Azithromycin 1.2 gm p.o.q. Wednesday.
Desitin DISEASE applied to affect area p.r.n.
Colace 100 mg p.o.b.i.d.
Ibuprofen 600 mg p.o.t.i.d.
Itraconazole 200 mg p.o.q.d.
Lansoprazole 30 mg p.o.q.d.
Levetiracetam 500 mg p.o.b.i.d.
Lidocaine jelly 2% applied to affected area.
Meclizine 25 mg p.o.b.i.d.
Metoclopramide 5 mg p.o.q.i.d.
Multivitamins one p.o.q.d.
Neutra-Phos one p.o.q.d.
Phenobarbital 90 mg p.o.b.i.d.
Ritonavir 100 mg p.o.b.i.d.
Sodium chloride nasal spray b.i.d.
Bactrim DS one p.o.q.d.
Tobramycin one drop applied to each eye q.i.d.

CONDITION AT DISCHARGE: Excellent.

DISCHARGE STATUS: Good.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4570**] M.D. [**MD Number(1) 4571**]

Dictated By:[**Name8 (MD) 4575**]
MEDQUIST36

D: [**2124-1-9**] 15:30
T: [**2124-1-9**] 15:29
JOB#: [**Job Number 4576**]
Admission Date: [**2140-1-8**] Discharge Date: [**2140-1-14**]

Date of Birth: [**2060-1-20**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Sulfonamides / Motrin / Erythromycin Base

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
dyspnea fatigue DISEASE

Major Surgical or Invasive Procedure:
central line placement


History of Present Illness:
78 F with h/o asthma DISEASE seen at [**Hospital1 18**] ED on [**1-7**] and found to have
LLL pneumonia. Pt was sent home on antibiotics and asked to
return on [**1-8**] were she was found to be increasingly dyspneic
tachycardic 120's and hypoxic 50% ( RA DISEASE ). Pt was immediately
intubated in the ED and found to have ABG of 71.5/69/556 after
intubation. Pt was transfered to the ICU for hypercarbic DISEASE
respitory failure DISEASE on [**1-8**].


Past Medical History:
1. asthma DISEASE
2. cataracts DISEASE
3. severe bilateral hearing loss DISEASE
4. allergic rhinitis DISEASE

Social History:
Lives alone in [**Location (un) **] MA. She is a widow. She has one
daughter that lives in [**Location 652**] CA. Her phone #
[**Telephone/Fax (1) 4577**]. She does not smoke or drink EtOH.

Family History:
no cancer DISEASE or diabetes DISEASE


Physical Exam:
T 98.9 BP 121/60 HR 120 RR 16
A/C 400x18 PEEP 8 FI02 50%
Gen: intubated sedated
HEENT: PERRL
Neck: supple no LAD
Lungs: diffuse b/l wheezingAdmission Date: [**2159-9-10**] Discharge Date: [**2159-9-25**]


Service:ORTHO
HISTORY OF PRESENT ILLNESS: This is an 82 year-old woman
with a history of hypertension DISEASE status post cerebrovascular
accident with residual left sided weakness status post right
CEA in [**2155**] who is admitted for an L4-S1 decompression/fusion
on [**9-10**]. The patient's postoperative course was
electrocardiogram with new T wave inversions laterally but
otherwise not significantly changed. The patient ruled out
by enzymes after this incident and was transferred to the
floor. The patient also received intraoperative Labetalol
for hypertension DISEASE . Telemetry overnight after her episode of
chest pain DISEASE demonstrated premature ventricular contractions DISEASE
and bigeminy DISEASE . The patient was seen by cardiology consult
pressure control. On [**9-14**] the patient began to
develop paroxysmal atrial fibrillation DISEASE with a rapid
ventricular response and was subsequently anticoagulated on
heparin and Coumadin and placed on Amiodarone. However on
[**9-18**] the patient's hematocrit dropped from 36 to 24
with a decrease in blood pressure and was found to have a
rectus sheath hematoma DISEASE . The patient received 6 units of
packed red blood cells 5 units of fresh frozen platelets and
her anticoagulation reversed. The patient was transferred to
the SICU where arterial line was placed and the patient was
placed on Nipride.

On [**9-21**] the patient was stable and transferred to the
floor with a resorbing hematoma DISEASE and a normal sinus rhythm.
She at that point was denying chest pain shortness DISEASE of
breath lightheadedness DISEASE although she was having some
abdominal tenderness DISEASE . She was noted to have been having some
trouble with po and is being followed by the speech and
swallow team and was also noted to have some confusion DISEASE and
mental status changes.

PAST MEDICAL HISTORY: 1. Hypertension. 2. Small vessel
cerebrovascular accident in [**2153-3-26**] with residual left
sided weakness. 3. Bilateral carotid stenosis DISEASE status post
right CEA in [**2155**] and with left CVBD. In [**2159-5-27**] the
patient was noted to have mild right ICA plaque DISEASE and 60 to 69%
[**Doctor First Name 3098**]. 4. Status post spinal fusion [**2159-9-10**]. 5.
Status post echocardiogram in [**2150**] demonstrating normal left
ventricular function and trace AI. Status post ETT in [**2150**]
with equivocal results. 6. Status post parotid gland
excision at [**Hospital1 2025**] for a tumor DISEASE .

MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg po q day. 2.
Detrol 1 mg po b.i.d. 3. Cozaar 25 mg po t.i.d. 4. MVI 1
po q.d. 5. Zoloft 25 mg po q.d.

ALLERGIES: The patient is Admission Date: [**2149-11-15**] Discharge Date: [**2149-12-5**]

Date of Birth: [**2080-11-2**] Sex: M

Service:

HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 68 year old gentleman
with a history of coronary artery disease DISEASE previous coronary
artery bypass graft with severe known aortic stenosis DISEASE who had
been scheduled for an aortic valve replacement on [**2149-11-17**] with Dr. [**Last Name (Prefixes) **]. The patient presented to the
Emergency Department on [**2149-11-15**] with increasing
shortness of breath DISEASE . The patient had previously been
admitted to Dr. [**Last Name (Prefixes) **] for apical aortic conization.
The procedure was aborted in the Operating Room due to
evidence of a significant amount of aortic insufficiency DISEASE .
The patient was subsequently discharged to home and scheduled
for






[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]

Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36

D: [**2149-12-4**] 17:02
T: [**2149-12-4**] 21:37
JOB#: [**Job Number 3871**]
Admission Date: [**2149-11-15**] Discharge Date: [**2149-12-5**]

Date of Birth: [**2080-11-2**] Sex: M

Service: CA/TH [**Doctor First Name 147**]

HISTORY OF PRESENT ILLNESS: This is a 69 -year-old male
patient who was admitted to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **]
[**Last Name (Titles) **] through the Emergency Department on [**2149-11-15**]
with increasing shortness of breath DISEASE . The patient had a
previous hospitalization from [**11-2**] through [**11-6**]
for which he was scheduled for an attempted apical
canalization. However he was found to have significant
aortic insufficiency DISEASE and the procedure was aborted.

Th[**Last Name (STitle) 1050**] was discharged home on [**2149-11-6**] without
diuretic and he was scheduled to undergo aortic valve
replacement on [**11-17**] with Dr. [**Last Name (Prefixes) **]. On
admission to the hospital the patient was noted to have a
chest x-ray which was significant for a right pleural
effusion as well as congestive heart failure DISEASE .

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post coronary artery
bypass graft times five in [**2140**].
2. Status post myocardial infarction DISEASE in [**2129**].
3. Aortic stenosis with aortic insufficiency DISEASE with a
calculated aortic valve area of 0.8-0.9.
4. Asthma.
5. ETOH abuse. The patient states that last drink was on
[**2149-11-15**]. The patient admits to smoking one pack a
dayAdmission Date: [**2149-11-15**] Discharge Date: [**2149-12-5**]

Date of Birth: [**2080-11-2**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: This is a 69 year old male
patient who was admitted to [**Hospital1 188**] through the Emergency Department on [**2149-11-15**]
with increasing shortness of breath DISEASE . The patient had a
previous hospitalization from [**11-2**] through [**11-6**] for which he was scheduled for an attempted apical
conization however he was found to have significant aortic
insufficiency DISEASE and the procedure was aborted. The patient was
discharged home on [**2149-11-6**] without diuretic and he
was scheduled to undergo aortic valve replacement on [**11-17**] with Dr. [**Name (STitle) 3876**].

On admission to the hospital the patient was noted to have a
chest x-ray which was significant for a right pleural
effusion as well as congestive heart failure DISEASE .

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post coronary artery
bypass graft times five in [**2140**].
2. Status post myocardial infarction DISEASE in [**2129**].
3. Aortic stenosis with aortic insufficiency DISEASE with a
calculated aortic valve area of 0.8 to 0.9.
4. Asthma.
5. ETOH abuseAdmission Date: [**2155-4-8**] Discharge Date: [**2155-4-9**]


Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Chief Complaint: lymphoma work-up
.
Reason for MICU transfer: airway monitoring

Major Surgical or Invasive Procedure:
None this hospitalization


History of Present Illness:
Patient is a [**Age over 90 **] yo F with hx nasal congestion and serous otitis DISEASE
media found to have nasopharyngeal mass now POD #6 s/p nasal
endoscopy w/ biopsy bilateral tube placement. Mass biopsy
returned w/ diagnosis of aggressive lymphoma DISEASE involving nasal
cavity and possible airway compromise. She was started on abx 4
days ago for bronchitis DISEASE . She was sent by Dr. [**Last Name (STitle) 3877**] for ENT
eval due to concern for airway involvement given extent of
tumor DISEASE . Pt denies fevers chills DISEASE n/v chest pain shortness DISEASE of
breath. She does endorse pain DISEASE in her left cheek.
.
In the ED initial VS were 98.5 72 152/116 16 99% RA DISEASE . Her labs
were notable for normal K Phos Ca uric acid but elevated LDH.
She was seen by ENT who did not recommend surgical intervention.
She had CT od head/ neck/ torso for staging. She received
dexamethasone 20 mg IV x 1 as well as allopurinol 300 mg po
daily. She was admited to [**Hospital Unit Name 153**] for airway monitoring. Her vital
signs prior to transfer were: 134/82 65 22 97% RA DISEASE .
.
On arrival to the ICU patient is comfortable with only mild
left sided facial pain DISEASE requesting to be discharged in the
morning.

Past Medical History:
Past Medical History:
NP mass- s/p biopsy showing lymphoma
HTN DISEASE
hypothyroidism DISEASE

Social History:
Lives alone. daughter visits once a week to help with shopping
household chores. she denies tobacco alcohol illicits.


Family History:
Denies cancer DISEASE in the family.


Physical Exam:
ADMISSION EXAM DISEASE :
.
General: Alert oriented no acute distress
HEENT: scleric anicteric MMM fullness DISEASE over left cheek and neck

Neck: supple JVP not elevated no LAD
Lungs: Clear to auscultation bilaterally no wheezes rales DISEASE
rhonchi
CV: Regular rate and rhythm normal S1 Admission Date: [**2142-12-27**] Discharge Date: [**2143-1-1**]

Date of Birth: [**2086-7-17**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**12-27**] MVR (25/33 ON-X mechanical valve)


History of Present Illness:
55 yo M with long history of myxomatous MV and chronic MR.
Serial echos showed increased LA/LV dimensions and and severe MR DISEASE
and normal EF. Referred DISEASE for surgery.

Past Medical History:
MR/MVP Migraines Ankylosing spondylitis GI bleed DISEASE (10 years
ago) Hyperlipidemia HTN B hernia DISEASE repair

Social History:
works as architect
quit tobacco 27 years ago
no etoh

Family History:
mother with MVR Admission Date: [**2176-3-19**] Discharge Date: [**2176-3-25**]

Date of Birth: [**2098-7-3**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Demerol

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional dyspnea DISEASE

Major Surgical or Invasive Procedure:
[**2176-3-19**]
1. Aortic valve replacement with a 27-mm [**Company 1543**] Ultra
Aortic Valve Bioprosthesis.
2. Epiaortic duplex scanning.


History of Present Illness:
Mr. [**Known lastname **] is a 77yo male with known aortic stenosis DISEASE and
coronary artery disease DISEASE . He has been followed with serial
echocardiograms which have shown progression of his aortic valve
disease. Over the last year to six months he
has developed slight exertional dyspnea DISEASE most notable on his one
mile walk which he does routinely as well as taking out the
trash barrels subtle but a change. Dr [**Last Name (STitle) 914**] was consulted for
surgical evaluation

Past Medical History:
Past Medical History
- Aortic Stenosis
- Coronary Artery Disease
- Dyslipidemia DISEASE
- Hypertension DISEASE
- Prior CVA affecting left eye ( 10 yrs ago)
- Carotid Disease Right ICA
- L subclavian steal
- Left Renal Artery Stent
- Chronic Renal Insufficiency baseline Cr around 2.0
- Rheumatoid Arthritis DISEASE
- Macular Degeneration ( legally blind)
- Cognitive Impairment DISEASE progressive memory loss DISEASE
- History of Mesenteric artery insufficiency DISEASE
- Cataracts DISEASE
- Anemia DISEASE
Past Surgical History:
-tonsillectomy
-R cataract DISEASE [**Doctor First Name **]


Social History:
-Tobacco history: quit 45 yrs ago used to smoke 1PPD x 25 yrs
-ETOH: drinks 4-6 beers on wknd
-Illicit drugs: denies



Family History:
Pt reports that his father had heart problems DISEASE but unsure what
kind as died when pt was 9 at age 60. [**Name (NI) 1094**] sister had a valve
replaced at age 81 but died at age 82 from colon cancer DISEASE . [**Name (NI) 1094**]
brother also had rhematic fever DISEASE when he was a child but died of
alcoholism DISEASE related causes.

Physical Exam:
Admission
Pulse: 60 Resp:16 O2 sat: 98%
B/P Right:124/54 Left: 96/55
Height: 67Admission Date: [**2157-2-1**] Discharge Date: [**2157-2-8**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Abdominal pain DISEASE

Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and biliary stent placement on [**2157-2-1**]

History of Present Illness:
Mrs. [**Known firstname 1929**] [**Known lastname 1930**] is a very nice 85 year-old woman with a
history of cholecystectomy and ampullar stenosis DISEASE who presents
with RUQ abdominal pain DISEASE . She states her pain DISEASE started 2 days
prior to admission was constant and radiated towards the back.
She had nausea vomit malaise DISEASE . Denies fever chills changes
in her bowel movements hematochezia DISEASE or melena DISEASE . Unable able to
tolerate oral intake.

Presenting vitals were T 101.5 HR 68 BP 152/76 RR 16 SpO2
95% RA DISEASE . In ED Unasyn 3gm given and a right IJ central line was
placed. She underwent ERCP that showed 1-cm stone in the common
bile duct. Patient became hypoxic from the conscious sedation
so the stone was not removed to expedite the procedure. A
plastic biliary stent was successfully placed. Post-ERCP she
was admitted to the ICU with a diagnosis of cholangitis DISEASE .

ICU course: In the ICU the patient was continued on Zosyn her
RUQ pain DISEASE significantly improved and she began to tolerate
fluids. On [**2-3**] she developed shortness of breath DISEASE that
improved with administration of furosemide. Nebulizer
treatments also given. At time of transfer to floor O2 sat was
95% on 2L nasal canula. Lisinopril restarted but Atenolol and
Nifedipine held for concern of lower heart rate.

She was transferred to the floor and felt improvement in her
abdominal pain DISEASE . Denied shortness of breath chest pain DISEASE .

Past Medical History:
1. Hypertension DISEASE
2. Ampullary stenosis
3. Status post cholecystectomy for gallstones DISEASE
4. History of sphincterotomy (as described above)
5. Osteoporosis DISEASE
6. Gastroesophageal reflux disease DISEASE
7. External hemorrhoids DISEASE
8. Cerebrovascular accident DISEASE in [**2145**] (right pontine)
9. Parkinson's DISEASE diseae
10. Chronic low back pain DISEASE with sciatica DISEASE
11. Urinary frequency and urge incontinence DISEASE
12. Diverticulosis
13. Chronic pancreatitis DISEASE

Social History:
She lives by herself. She came the US in [**2138**] from [**Country 1931**] and
is Russian-speaking. Denies alcohol tobacco and no drugs.

Family History:
No family of MI stroke DISEASE son prostate cancer DISEASE . Daughter with
[**Name2 (NI) 1932**].

Physical Exam:
Admission Exam:
VS: Temp 97.8 F BP 108/30 mmHg HR 78 BPM RR 14 O2-sat 93%
RA DISEASE
GEN: Well-appearing woman in NAD comfortable jaundiced DISEASE (skin
mouth conjuntiva)
HEENT: NC/AT PERRLA EOMI sclerae icteric DISEASE MMM OP clear
NECK: Supple no thyromegaly no JVD no carotid bruits DISEASE
LUNGS: CTA bilat no r/rh/wh good air movement resp unlabored
no accessory muscle use
HEART: PMI non-displaced RRR no MRG nl S1-S2
ABDOMEN: NABS soft/NT/ND no masses or HSM no
rebound/guarding.
EXTREMITIES: WWP no c/c/e 2Admission Date: [**2138-9-2**] Discharge Date: [**2138-9-7**]

Date of Birth: [**2073-1-19**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC:[**CC Contact Info 3898**]

Major Surgical or Invasive Procedure:
s/p anterior cervical discectomy C2-C3


History of Present Illness:
HPI: 65M was outdoors cutting tree branch when 700# branch hit
him on the head. He was found upside down in his harness with
the
branch on the ground. Found to have L occipital laceration DISEASE that
was stapled at OSH. GCS DISEASE 15. Transferred to [**Hospital1 18**] for further
evaluation.


Past Medical History:
htn

Social History:
lives alone
ex wife lives on [**Location (un) 945**]

Family History:
unknown


Physical Exam:
On arrival
PHYSICAL EXAM DISEASE :
afeb 68 145/70 22 96%
Gen: WD/WN comfortable NAD.
HEENT: Pupils: R 2.5-Admission Date: [**2179-11-2**] Discharge Date: [**2179-11-5**]

Date of Birth: [**2123-11-14**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
diabetic ketoacidosis DISEASE

Major Surgical or Invasive Procedure:
central line placement in ED


History of Present Illness:
Pt is a 55 yo F with no significant PMH who presented to PCP
[**Name Initial (PRE) 151**] 3 days of profound fatigue DISEASE and DOE. Pt states she Admission Date: [**2100-12-21**] Discharge Date: [**2100-12-23**]

Date of Birth: [**2034-6-22**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Bactrim

Attending:[**Doctor First Name 1402**]
Chief Complaint:
post ablation complication

Major Surgical or Invasive Procedure:
Pulmonary Vein DISEASE Isolation unsuccessful
Pericardial Drain


History of Present Illness:
Ms. [**Known lastname 3912**] is a 66 y/o F with a history of pAtrial Fibrillation DISEASE
(not controlled on Flecanide/DigoxinAdmission Date: [**2103-9-27**] Discharge Date: [**2103-10-30**]

Date of Birth: [**2058-7-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Bleomycin / Bactrim

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
45 yo M with a long history of recurrent Hodgkin's lymphoma DISEASE s/p
auto and allogeneic transplant with recurrence on monthly
chemotherapy admitted after he presented for scheduled
chemotherapy with fevers DISEASE to 101 in clinic and transferred to the
ICU for persistent hypotension DISEASE after bronchoscopy.
.
The patient initially presented to clinic on [**2103-9-27**] for
scheduled Gemzar navelbine and decadron therapy. He was found
to have a fever DISEASE to 101. On review of systems at that time the
patient did admit to feeling fatigued and generally unwell
possibly with a component of pleuritic chest pain DISEASE and dry cough DISEASE .
CXR at that time revealed an evolving RLL and lingular/LUL
infiltrate. He was admitted for further evaluation with CXR and
CT chest concerning for evolving pneumonia DISEASE . The patient was
started on Vancomycin Cefepime and Voriconazole. During his
hospital stay the patient did have relative hypotension DISEASE as at
baseline to the range of sbp 90's with tachycardia DISEASE to the low
100's. The patient did have individual sbp measurements
overnight prior to transfer as low as 80's reportedly fluid
responsive.
.
The patient was brought to the ICU for elective bronchoscopy.
During the procedure the patient received 1mg midazolam and a
bolus of 25mcg of fentanyl. Post-procedure the patient was
persistently hypotensive DISEASE to the range of sbp 78-82 with intact
mentation though some complaints of feeling tired and mildly
lightheaded. His hypotension DISEASE was refractory to 1L of NS. The
patient was kept in the [**Hospital Unit Name 153**] for further monitoring.
.
Of note the patient has a history of multiple episodes of
pneumonia DISEASE in the past most recently with fungal pnuemonia DISEASE based
upon positive galactomannan in [**1-6**].
.
ROS: Denies any recent sick contacts. Notes mild pleuritic chest
pain DISEASE and nausea DISEASE . No emesis abdominal pain diarrhea DISEASE brbpr
urinary complaints DISEASE .

Past Medical History:
Past medical/surgical history:
Hodgkin's disease DISEASE (see below)
Hypothyroidism DISEASE
Asthma
s/p biliary stent (see below)
Hepatitis B DISEASE coreAdmission Date: [**2103-11-2**] Discharge Date: [**2103-11-21**]

Date of Birth: [**2058-7-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Bleomycin / Bactrim / IV Dye Iodine Containing

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Respiratory distress DISEASE

Major Surgical or Invasive Procedure:
Mechanical ventilation ([**Date range (1) 3927**]/08)

History of Present Illness:
45 yo M with PMH of recurrent Hodgkin's lymphoma DISEASE (since [**2094**])
s/p auto and allogeneic transplant with recurrence last
chemotherapy (gemcitabine navelbine decadron [**2103-8-30**]) Admission Date: [**2104-2-28**] Discharge Date: [**2104-3-7**]


Service: MEDICINE

Allergies DISEASE :
Xanax / Ativan

Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Tachycardia DISEASE feeling unwell

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Age over 90 **] M with pacemaker admitted for rapid afib. In [**2102**] he had a
dual chamber St. [**Male First Name (un) 1525**] pacemaker placed for symptomatic
bradycardia DISEASE and chronitropic incompetence and has been doing
fairly well. He walks his dog 1.5 miles daily. This morning he
woke up feeling lousy and tried to walk the dog but could only
make it down the block and had to turn back. Did not have enough
energy and felt some lightheadedness. No chest pain DISEASE or shortness
of breath. He called [**Hospital **] clinic who interogatted the pacer over
the phone and found him tachycardic. He was told to go to the
ED.

Otherwise he feels well. On review of systems denies fevers DISEASE
chills nausea vomit DISEASE abd pain diarrhea DISEASE . On cardiac review of
systems denies orthopnea PND or increase in peripheral edema DISEASE .


In the ED vitals were: 98.6 128 144/85 24 100%RA. Because
of his fast heart rates he was given dilt 10 IV x 3 and dilt 30
mg PO followed by 60 mg PO.


Past Medical History:
# Chronic renal failure DISEASE
- Followed by Dr. [**Last Name (STitle) **]. On Epogen.
- Baseline creatinine is 2.0 - 2.4.
# Claudication DISEASE
- Walks 1.5 miles daily but has to stop and rest.
# Aortic stenosis DISEASE
- Mean gradient 60 on last ECHO [**9-6**]
- Declined AVR or valvuloplasty
# B12 deficiency DISEASE
# HTN DISEASE
# GERD
# PVD
# H/O stomach cancer DISEASE
- s/p total gastrectomy and Roux-en-Y in late [**2085**]
# Left renal artery stenosis DISEASE
- s/p stenting [**2102-3-8**]
# Type 2 DM
# Hyperkalemia DISEASE in the past attributed to dietary supplements
# Paroxysmal atrial fib
- reported after gastrectomy but no h/o recurrence
# COPD DISEASE
# TIA DISEASE
# Abdominal aortic aneurysm DISEASE repair
# Right ICA 50% occluded [**Doctor First Name 3098**] 90% occluded


Social History:
Lives at home with his wife. [**Name (NI) **] [**Name (NI) **] [**Known lastname 3937**] is a ED physician
in [**Name9 (PRE) 1727**]. Phone numbers are [**Telephone/Fax (1) 3938**] and [**Telephone/Fax (1) 3939**].
Patient is a retired jazz musician--- played the clarinet and
sax. No ETOH or drugs. Smoked [**3-4**] PPD for 30 years but quit
approximately 20 years ago.


Family History:
No fam hx or early CAD.

Physical Exam:
VITALS: 97.1 143/62 76 20 100%2LNC
GEN: AAdmission Date: [**2104-10-28**] Discharge Date: [**2104-10-31**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Xanax / Ativan

Attending:[**First Name3 (LF) 3948**]
Chief Complaint:
Hemoptysis DISEASE

Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Flexible bronchoscopy with therapeutic aspiration

History of Present Illness:
[**Age over 90 **] yo man with aortic stenosis CRF left renal artery stenosis DISEASE
COPD DISEASE tobacco abuse who called EMS for acute dyspnea/hemoptysis
last night. Had approx 5 tbl of BRB followed by a few episodes
of coin sized blood.

Per patient's wife patient was lethargic and sleepy after d/c
last week from hospital. [**Name (NI) **] wife awoke around 230am
today when patient was coughing up blood and DISEASE noted to be
dyspneic. She also states that the VNA noted some Admission Date: [**2135-6-15**] Discharge Date: [**2135-7-22**] Service: Vascular Surgery

CHIEF COMPLAINT: Ruptured infected right femoral
pseudoaneurysm DISEASE .

HISTORY OF PRESENT ILLNESS: This 82 year old white female
with coronary artery disease coronary artery bypass graft cerebrovascular accident diabetes hypertension renal artery stenosis DISEASE status post left renal artery stent
peripheral vascular disease DISEASE had undergone a right common
femoral to anterior tibial artery bypass graft with PTFE on
[**2132-11-27**] by Dr. [**Last Name (STitle) **]. After the patient developed
gangrene DISEASE of her lower saphenectomy site with two ulcers DISEASE .

The patient did well until she had a catheterization via her
right groin in [**2135-4-28**]. The patient
developed a right groin hematoma DISEASE which was evacuated in [**2135-4-28**]. At that time there was no graft involvement.

The patient was sent to the [**Hospital6 2018**] Emergency Room from [**Hospital6 310**] on
[**2135-6-15**] with recent history of fevers DISEASE and development
of a pulsatile mass in her right groin. The right groin
began to bleed DISEASE and the patient was sent for evaluation. In
the Emergency Room the patient was diagnosed with an infected
pseudoaneurysm DISEASE and was admitted for emergency surgery.

PAST MEDICAL HISTORY:
1. Coronary artery disease: NWQMI percutaneous
transluminal coronary angioplasty/stent [**2132-6-23**]
coronary artery bypass graft [**2132-8-24**].
2. Cerebrovascular accident [**2128**] no residual.
3. Right medullary cerebrovascular accident [**2135-3-29**].
4. Seizure disorder hospitalized [**2129-4-28**] at [**Hospital6 1760**].
5. Diabetes diagnosed in [**2123**].
6. Hypertension DISEASE .
7. Hypercholesterolemia DISEASE .
8. Carotid artery stenosis DISEASE .
9. Renal artery stenosis stent placement left renal artery
[**2135-3-29**].
10. Recurrent urinary tract infection DISEASE .
11. Severe depression DISEASE status post electroconvulsive therapy
[**2123**] and [**2125**].
12. Left femoral neck fracture.
13. Right groin hematoma DISEASE .
14. Recurrent urinary tract infections DISEASE .
15. Peripheral vascular disease DISEASE .

PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times three with right leg
saphenous vein on [**2132-8-24**] by Dr. [**Last Name (STitle) **] at [**Hospital6 1760**].
2. Right common femoral to anterior tibial artery bypass
graft with PTFE and distal tailor vein patch on [**2132-11-27**] by Dr. [**Last Name (STitle) **].
3. Left closed reduction internal fixation of left hip
fracture DISEASE and evacuation of right groin hematoma DISEASE on [**2135-5-2**] at [**Hospital6 256**].

ALLERGIES: No known drug allergies DISEASE .

ADMISSION MEDICATIONS:
1. Aggrenox
2. Aspirin
3. Lisinopril
4. Amlodipine
5. Atorvastatin
6. Lopressor
7. Bupropion
8. Mirtazapine
9. Temazepam
10. Trazodone
11. Dulcolax
12. Tylenol
13. Sublingual Nitroglycerin
14. RISS
15. Vancomycin

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: The patient was at [**Hospital6 3953**] prior to admission. She does not drink alcohol. She
does not smoke cigarettes. She has a son daughter-in-law
and daughter who are very involved in her care.

ADMISSION LABORATORY DATA: White blood count 9.4 hemoglobin
7.8 hematocrit 22.5 platelets 314000 PT 13.9 PTT 28.8
INR 1.3. Sodium 143 potassium 4.5 chloride 108
bicarbonate 26 BUN 54 creatinine 1.1 glucose 124.

HOSPITAL COURSE: The patient was evaluated in the Emergency
Room. She was noted to have a bleeding DISEASE pulsatile mass in her
right groin. She had a fever DISEASE to 102. She was taken to the
Operating Room for emergent repair of her infected right
groin pseudoaneurysm DISEASE . The proximal prosthetic graft was
removed. The distal prosthetic graft could not be separated
from the surrounding tissue and therefore was ligated. A
right common femoral to profunda femoris artery bypass graft
with right superficial femoral artery was done. The patient
received 6
units of packed red blood cells intraoperatively for her
hematocrit of 22. Post transfusion hematocrit was 33.7.
The patient was kept on heparin infusion. She was started on
Vancomycin Levofloxacin and Flagyl. At the end of surgery
the patient had a cool right lower extremity from the foot to
the knee. No doppler signals were found at the dorsalis
pedis DISEASE or posterior tibial. Dr. [**Last Name (STitle) **] felt there was no
possibility of revascularization. He discussed the necessity
of an above the knee amputation in the future with the
family. Postoperatively the patient remained intubated. Her
urine output decreased considerably. She was determined to
be in metabolic acidosis DISEASE . Tube feedings were started via
oral gastric tube. Blood cultures grew Methicillin-resistant DISEASE
Staphylococcus aureus. Tissue culture grew
Methicillin-resistant Staphylococcus DISEASE aureus.

The Renal Service was consulted for the patient's oliguria DISEASE
and elevated creatinine from 1.5 to 2.2. Because of her
renal artery stenosis DISEASE and recent left renal artery DISEASE stent
placement they felt the patient's right kidney was not
functioning. They therefore recommended that her systolic
blood pressure be kept greater than 140 and less than 180 to
maintain adequate renal perfusion. In the meantime until
renal function improved all medications were to be dosed for
a creatinine clearance of approximately 25 cc/hr.

The patient failed multiple attempts to wean her to
extubation. She was felt to be fluid overloaded as well as
having extremely thick secretions. She was diuresed with
Lasix prn and then a Lasix drip. She had a bronchoscopy on
[**2135-6-27**] and secretions grew Methicillin-resistant DISEASE
Staphylococcus aureus. Chest x-ray showed a left lung
collapse and she had a repeat bronchoscopy on [**2135-7-1**].
Secretions again grew Methicillin-resistant Staphylococcus DISEASE
aureus. On [**2135-7-2**] large pleural effusion DISEASE was seen and
the patient underwent ultrasound-guided aspiration of the
left pleural effusion DISEASE . One liter of fluid was drained.
Cultures were negative. Possibility of a tracheotomy was
discussed with the family who refused to consider it at that
time. Following the pleural tap the patient continued to
improve and was finally extubated [**2135-7-6**].
Postoperatively she did fairly well with Albuterol and
Ipratropium inhalation as well as Albuterol and Ipratropium
nebulizer treatment as needed. Aggressive chest physical
therapy was also used to help clear her secretion.

After extubation the patient continued to receive total
parenteral nutrition. Bedside speech and swallow evaluation
could not be done. The patient refused all food and refused
to take part in the swallow evaluation. The patient's family
was able to bring in homemade foods which the patient was
able to eat small quantities. A repeat bedside evaluation
done on [**2135-7-12**] showed definite aspiration. Aspiration
precautions were put in place. The patient's family
consented to place a percutaneous endoscopic gastrostomy.
The patient was then NPO except for medications.

The patient's right leg deteriorated significantly. Family
discussed right above the knee amputation and percutaneous
endoscopic gastrostomy placement with the patient on [**2135-7-15**]. A decision was made to go ahead with both procedures
on [**2135-7-18**]. The patient and family requested
Do-Not-Resuscitate/Do-Not-Intubate status.

The patient had developed some redness along her right groin
wound with minimal drainage. Levofloxacin and Flagyl were
added to her Vancomycin. Her abdominal staples had been
removed on [**2135-7-1**].

The patient had urine culture which grew 10000 to 100000
yeast. This was treated with three days of intravenous
Fluconazole. A stool culture from [**2135-7-8**] was sent and
was Clostridium difficile DISEASE positive. The patient was started
on a two week course of Flagyl on [**2135-7-11**].

At the time of dictation the patient's right groin wound is
almost healed. She will have dry sterile dressing changes
b.i.d. Her abdominal incision is clean dry DISEASE and intact. Her
right above the knee amputation incision is clean dry DISEASE and
intact. Staples should remain for one month from surgery
before removal. Appointment with Dr. [**Last Name (STitle) **] in the office
should be made for removal. The patient should continue her
Vancomycin through [**2135-7-27**]. She has been dosed per
level less than 15. At the time of dictation she has a
random Vancomycin level pending and should receive 1 gm of
intravenous Vancomycin today. The patient will finish her
Flagyl on [**2135-7-25**] for her Clostridium difficile DISEASE
treatment.

MEDICATIONS ON DISCHARGE:
1. Vancomycin through [**2135-7-27**] for
Methicillin-resistant Staphylococcus DISEASE aureusAdmission Date: [**2137-1-18**] Discharge Date: [**2137-2-4**]


Service: VSU


HISTORY OF PRESENT ILLNESS: Patient is an 83-year-old
Russian only speaking female admitted due to likely
cellulitis DISEASE of her right above the knee amputation stump. Her
history was limited by absence of a family member or
translator at the time of interview and the remainder of her
history was obtained from her medical record.

Past medical history includes coronary artery disease DISEASE status
post percutaneous transluminal coronary angioplasty and stent
in [**2131**] coronary artery bypass graft in [**2132-7-29**]
cerebrovascular accident DISEASE in [**2128**] right medullary
cardiovascular accident DISEASE in [**2135-3-29**] seizure disorder DISEASE
diabetes hypertension hypercholesterolemia DISEASE carotid artery
stenosis renal artery stenosis DISEASE status post stent placement
in the left renal artery recurrent urinary tract infection DISEASE
severe depression DISEASE status post ECT therapy left femoral neck
fracture DISEASE right groin hematoma DISEASE recurrent urinary tract
infections DISEASE peripheral vascular disease DISEASE .

Past surgical history includes repair of a ruptured infected DISEASE
right femoral pseudo aneurysm DISEASE coronary artery bypass graft
right common femoral to anterior tibial artery bypass graft
with a PTFE and distal talar vein patch in [**2131**] by Dr.
[**Last Name (STitle) **] left closed reduction internal fixation of the left
hip fracture DISEASE and evacuation of right groin hematoma DISEASE .

SOCIAL HISTORY: Patient does not drink alcohol. She does
not smoke cigarettes. She has a son and daughter-in-law and
daughter who are involved in her care.

PHYSICAL EXAMINATION: Temperature 98.8 heart rate 70 blood
pressure 118/74 sating 96 percent on room air. In general
the patient was alert in no acute distress. She has slight
scleral icterus DISEASE and some sublingual icterus DISEASE . Heart is
regular rate and rhythm. Lungs are clear to auscultation
bilaterally. Abdomen is soft nontender obeseAdmission Date: [**2120-9-20**] Discharge Date: [**2120-9-30**]

Date of Birth: [**2075-5-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3958**]
Chief Complaint:
Presyncope

Major Surgical or Invasive Procedure:
Pericardial window

History of Present Illness:
This is a 45 y/o female with past medical history of
hypothyroidism DISEASE presenting initially for an urgent care visit
with an episode of diaphoresis and presyncope DISEASE several hours
prior. The patient has had Admission Date: [**2182-10-17**] Discharge Date: [**2182-11-3**]

Date of Birth: [**2104-4-10**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Milk

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
s/p ERCP with acute mental status changes/aspiration PNA

Major Surgical or Invasive Procedure:
ERCP with sphincteroplasty
PEG tube placement (via Interventional Radiology)


History of Present Illness:
77 y/o F with PMhx of Developmental Delay COPD HL HTN DISEASE and
Mirizzi syndrome DISEASE who presented today for elective ERCP. Pt was
felt to be functionning at baseline prior to procedure with mild
agitation DISEASE pulling at PIVs but interacting with staff. She was
given fent/midaz for ERCP with stent placement and was
transferred to the post-ERCP suite in stable condition. She had
elevated BPs during the procedure requiring labetalol and
metoprolol. She was found mildly tachypneic/wheezing with emesis DISEASE
on her gown. It was felt likely that she had an aspiration event
with low grade temp However she was still moving all four
extremities and responding appropriately to questions though
mildly sedated prior to transfer to the floor.
.
On arrival to the floor pt was minimally responsive to sternal
rub and did not withdraw to focal stimuli. She was notably
tachypneic and eyes were deviated to right side. She was able
to track to left with stimuli and would intermittently open eyes
to command. Pt had an ABG 7.4/36/92 with lactate of 3.5 and
CXR showed a right lower lobe infiltrate. Due to concern for
acute intracranial hemmorrhage DISEASE she was taken down for a stat CT
head. On return to the floor pt was given narcan without any
significant change in mental status. Neuro was consulted for
possible acute stroke DISEASE and within a few minutes she became more
responsive opening eyes spontaneously. By the time neuro came
to bedside pt was able to verbalize her name and was noted to
be using the right arm and had left sided deficit. A CODE
stroke DISEASE was called and pt was taken for urgent CTA head which did
not show any vessel obstruction DISEASE and TPA was felt unlikely to be
helpful. Perfusion images confirmed right temporal
hypoperfusion DISEASE consistent with clinical exam and likely right MCA
infarct DISEASE . ICU consult was initiated and pt's guardian was
notified. Pt was given Vanc/Cefepime and Aspirin 300mg PR while
awaiting ICU transfer. She was lying flat per neuro recs and
was noted to be spitting up bilious emesis DISEASE . Head of bed was
elevated and pt was suctionned prior to transferred to the ICU
for closer monitoring of airway and management of acute
pneumonia DISEASE .

Past Medical History:
Hypertension DISEASE
Developmental Delay
Mirizzi Syndrome DISEASE
COPD DISEASE


Social History:
At baseline pt lives at a nursing home and is able to feed
herself undress and can transfer from chair to bed but is
otherwise wheelchair bound. No smoking/ETOH history documented.

Family History:
none relevant to this hospitalization.

Physical Exam:
Admission:
T 101 BP 152/86 HR 86 RR 30 Sats 94% RA DISEASE
GEN: somnolent open eyes to vigorous stimulous
HEENT: Eyes deviated to right tracks to left with startle
CV: RRR no apprec m
RESP: diffuse expiratory wheezes moving air well
ABD: soft [**Month (only) **] BS no rebound/guarding
GU: foley in place
EXTR: warm minimal edema DISEASE toes upgoing
NEURO: minimally responsive eyes deviated no withdrawal to
painful stimuli

Pertinent Results:
[**2182-10-17**] 04:02PM BLOOD WBC-24.8*# RBC-6.40* Hgb-13.9 Hct-43.8
MCV-68* MCH-21.6* MCHC-31.6 RDW-14.3 Plt Ct-273
[**2182-11-2**] 05:55AM BLOOD WBC-8.1 RBC-5.33 Hgb-11.8* Hct-38.1
MCV-72* MCH-22.2* MCHC-31.0 RDW-14.8 Plt Ct-399
[**2182-11-1**] 06:05AM BLOOD Glucose-113* UreaN-4* Creat-0.5 Na-141
K-3.5 Cl-106 HCO3-27 AnGap-12
[**2182-10-28**] 06:05AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.9
[**2182-10-17**] 04:02PM BLOOD ALT-92* AST-118* AlkPhos-247* TotBili-1.4
[**2182-10-18**] 04:42AM BLOOD ALT-145* AST-277* AlkPhos-136*
Amylase-101* TotBili-0.5
[**2182-10-28**] 06:05AM BLOOD ALT-50* AST-46* LD(LDH)-170 AlkPhos-144*
TotBili-0.3
[**2182-10-21**] 06:36AM BLOOD Triglyc-143 HDL-44 CHOL/HD-3.8 LDLcalc-93
[**2182-10-21**] 06:36AM BLOOD %HbA1c-9.4* eAG-223*
.
ERCP [**2182-10-17**]
Procedures: A plastic stent was removed.
Impression: 2 balloon sweeps were performed with a small stone
sludge and debris removed. A 1.5 cm biliary stricture DISEASE in mid-CBD
compatible with known cystic duct stone DISEASE and mirrizi syndrome DISEASE was
visualized. A 10 F 5cm double pigtailed catheter was placed.
Otherwise normal ercp to third part of the duodenum.

CXR [**2182-10-17**] IMPRESSION: Right lower lobe pneumonia DISEASE with
atelectasis DISEASE or pneumonia DISEASE at the left base.
.
CTA HEAD W&W/O C & RECONS IMPRESSION: Moderate-to-severe
intracranial atherosclerotic disease DISEASE with findings suggestive of
decreased perfusion to the right MCA/PCA watershed region. The
findings may represent cerebral ischemia DISEASE in the setting of
hypovolemia hypotension DISEASE or other causes of decreased cardiac
output.
.
Cardiac Echo: IMPRESSION: Small LV cavity size with mild
symmetric LVH DISEASE and hyperdynamic LV systolic function.
Consequently there is a mild to moderate LV outflow tract
gradient. No pathologic valvular abnormality DISEASE seen.
.
RUE LENI IMPRESSION: Partially occlusive thrombus DISEASE in the right
basilic and axillary veins at site of PICC line. Clot does not
extend more centrally.
.
ABDOMEN (SUPINE ONLY) PORT IMPRESSION: Limited view of the
abdomen demonstrating no evidence for obstruction DISEASE . Bladder
stone.

Coags:
[**2182-11-1**] 06:05AM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1
[**2182-11-2**] 05:55AM BLOOD PT-14.0* INR(PT)-1.2* (Started Warfarin
5 mg)

Brief Hospital Course:
77 y/o F with PMhx of Developmental Delay COPD HL HTN DISEASE and
Mirizzi syndrome DISEASE who presented on [**10-17**] for elective ERCP. Pt
was noted to have emesis DISEASE on her gown in the post procedure suite
with diffuse wheezes and low grade temp. It was thought likely
that she had an aspiration event and when she was arrived on the
floor she had a profoundly depressed DISEASE mental status tachypnea DISEASE
and fever DISEASE to 101.9. Further stat work up revealed evidence of
aspiration PNA leukocytosis DISEASE and elevated lactate. Initial head
imaging was unrevealing. However she became more alert and was
noted to have an acute left sided deficit. CODE STROKE was
called and CTA/perfusion images confirmed right sided
hypoperfusion DISEASE likely consistent with right MCA stroke. Neuro
felt there was no indication for TPA given patent intracranial
vessels and on return to the floor pt was noted to have bilious DISEASE
secretions that she was having difficulty clearing. She was
transferred to the ICU for airway monitoring overnight. Pt was
called out to the floor when she was able to cough DISEASE and spit up
secretions. She was noted to have a waxing and [**Doctor Last Name 688**] mental
status sometimes will respond to commands and other times will
not. BP was allowed to autoregulate for the first 72 hrs post
event and pt was continued on Aspirin 300mg daily. She was
noted to have recovery of left arm function and was answering
yes/no to questions.

She was seen by PT/OT who recommended ongoing therapy upon
return to NH.
After discussion with HCP/guardian decision was made to avoid
follow up MRI as it was not likely to change care plan and pt
was unlikely to tolerate the procedure. Echo was performed to
rule out cardioembolic DISEASE source which did not show any thrombus DISEASE .
Lipid panel showed LDL in the 93 and Hgb A1c 9.4. She was
hyperglycemic during the hospitalization and she was started on
Lantus and sliding scale insulin.
.
Aspiration PNA: Pt was noted to have aspiration event s/p
procedure and was monitored in the ICU for 24hrs given concern
for her ability to protect airway . Leukocytosis lactate and
fevers DISEASE resolved after initiation of Vanc/Cefepime/Flagyl.
Respiratory status improved and pt had a PICC placed and she
completed a course of antibiotics.

Upper Extremity DVT- Patient was subsequently developed a DVT DISEASE
associated with the PICC line. The PICC line was discontinued
and she was started on Lovenox. Once a PEG tube was placed she
was started on Warfarin for a goal INR of [**2-6**]. Please follow
INR closely and titrate prn. She received her first dose of
Warfarin 5 mg on [**11-2**].

Aspiration - Pt was seen by speach/swallow on multiple
occasions which she grossly failed with aspiration. She was
kept strictly NPO and she was maintained with IV medications
and hydration. A dobhoff was placed for initiation of tube
feeds while waiting to see if she would regain her swallow
function. It is/was hoped that her swallow function would
improve especially considering her significant recovery in her
left arm movement however she did not show significant
improvement on serial exams. In discussion with Speech and
Swallow however there is some hope that she may recover her
swallow on a long term basis and Swallow therapy may help with
this recovery. They suggested an approximate 50% chance of
recovery to the point of safe oral intake in the long-term.
.
Diabetes-Pt with uncontrolled hyperglycemia DISEASE after the initiation
of tube feeds. Her lantus and insulin sliding scales were
agressively increased. She is being discharged on 70 units of
lantus and a sliding scale.
.
Mirizzi Syndrome DISEASE s/p ERCP: Pt with abnormal biliary anatomy DISEASE who
underwent stent and sphincteroplastyon [**10-17**] for recurrent abd
pain DISEASE . She was noted to have an acute rise in transaminases post
procedure and these trended down with normal Tbili. Pt was
followed by ERCP team while in house.
.
Developmental Delay: baseline confirmed with her guardian/mother
and nursing home.
.
HTN DISEASE : held BP meds to allow autoregulation s/p stroke DISEASE . She was
subsequently treated with IV metoprolol clonidine patch and IV
lasix with benefit. After obtaining access via PEG a blood
pressure medication regimen via PEG was begun. I expect that she
will benefit from further titration of medications as an
outpatient. Please note that she was also started on
LisinoprilAdmission Date: [**2197-6-15**] Discharge Date: [**2197-6-16**]

Date of Birth: [**2155-12-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Bactrim / Trazodone / Indinavir / Flovent HFA / LMA mask

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
hypoxia DISEASE

Major Surgical or Invasive Procedure:
endotracheal intubation
laser vaporization of the vulva

History of Present Illness:
The patient is a 41-year-old female
with past medical history of HIV/AIDS (CD4 392 and viral load
undetectable in [**2197-5-2**]) on Atripla history of
depression/anxiety hypertension chronic kidney disease DISEASE
cervical and vaginal dysplasia DISEASE and laryngeal papillomatosis DISEASE as
well as abnormal urinary cytology admitted to the ICU following
laser vaporization of the vulva DISEASE complicated by immediate post-op
desaturation DISEASE on waking up intubated in OR.

Per report the procedure went well without complication. She was
in her normal state of health prior to the procedure. Intra-op
she received a total of 2L of fluid intraoperatively. An LMA was
used. Towards the end of the case she was noted to move
suddenly. She was given a bolus dose of propofol. Following the
case she was able to breath on her own for 5-1o mintues she then
became aggressive and bit down on the LMA disloging the tube.
This was followed by an acute desaturation to the 70-80s. She
was given more propofol for sedation and mask ventilated with
some difficulty. She was intubated with blood noted in the tube.
Over the course of an hour she was noted to be much easier to
ventilate on exam lungs were noted to clear. She was then
transferred to the [**Hospital Unit Name 153**] for further management.

On arrival to the MICU patient's VS 92.4 59 97/71 12 100% SpO2
CMV Vt 500 mL PEEP of 10. Patient was intubated and sedated with
blood noted in the ET tube.

Review of systems:
unable to obtain


Past Medical History:
1. HIV diagnosed in [**2177**] at the time of bilateral lobar
pneumonia DISEASE complicated by ARDS DISEASE . Risk factor heterosexual sex.
CD4 nadir reportedly 186.
2. Cocaine abuse clean since [**2180**]Admission Date: [**2201-2-10**] Discharge Date: [**2201-2-17**]

Date of Birth: [**2143-10-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Codeine / Streptokinase / Iodine

Attending:[**First Name3 (LF) 3991**]
Chief Complaint:
Left Total Knee Replacement

Major Surgical or Invasive Procedure:
Left Total Knee Replacement


History of Present Illness:
57-year-old male with a past medical history significant for
severe bilateral arthritis DISEASE S/P R TKR in [**10-8**]Admission Date: [**2201-8-19**] Discharge Date: [**2201-8-25**]

Date of Birth: [**2143-10-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Codeine / Streptokinase / Iodine / Bee Pollens

Attending:[**First Name3 (LF) 3991**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
57M with AF DISEASE on coumadin h/o dvt CHF DISEASE CAD h/o MI COPD DISEASE on 4L
home O2 4 prior intubations for PNA who presented with 4d of
worsening SOB. He was admitted at [**Hospital3 3583**] approximately
5 wks ago for PNA and intubated for approximately 6 days. At
baseline he takes 160mg Lasix TID. He began to feel short of
breath 4 days prior to admission at [**Hospital1 18**] with orthopnea DISEASE mild
cough DISEASE with one episode of coughing up brown non-bloody sputum
and fever DISEASE to 100 on the morning of admission with no prior
known fevers DISEASE . He reports weight loss DISEASE of 20lb over the past few
weeks and more than 80lbs over the past year secondary to poor
appetite. He denied any recent sick contact/travel missed
medication doses or dietary alterations.
In the ED initial vs were T 97.6 HR 120 BP 186/103 RR 20 sat
96% 5L. Prior to transfer to ICU vs were HR 108 afib BP
131/101 RR 15 95% on 5L. The patient was given
vanco/ceft/azithro (without cultures) nebs and K repletion.
CXR showed cardiomegaly DISEASE bilateral pleural effusions DISEASE RAdmission Date: [**2201-8-28**] Discharge Date: [**2201-9-15**]

Date of Birth: [**2143-10-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Codeine / Streptokinase / Iodine / Bee Pollens

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
57M with PMH of atrial fibrillation DISEASE on coumadin systolic Admission Date: [**2155-7-4**] Discharge Date: [**2155-7-8**]

Date of Birth: [**2082-11-22**] Sex: M

Service: Blue Surgery

HISTORY OF PRESENT ILLNESS: Briefly this is a 72-year-old
male who is status post repair of a left inguinal hernia DISEASE on
[**2155-6-26**] who had been discharged home later in the day who
had been feeling well until one day prior to admission when
he began to have fevers DISEASE up to 101 and also had some chest
pressure. He saw Dr. [**Last Name (STitle) 957**] in the office who was
concerned and sent the patient to the Emergency Room for
evaluation. He denies chest pain shortness DISEASE of breath
nausea vomiting diarrhea DISEASE or any other symptoms.

PAST MEDICAL HISTORY:
1. Prostate cancer DISEASE status post prostatectomy.
2. Hypertension DISEASE .

ALLERGIES: Erythromycin.

MEDICATIONS:
1. Triamcinolone.
2. Lipitor.
3. Zestril.
4. Terazosin.
5. Allopurinol.

SOCIAL HISTORY: He does not smoke and he does not drink.

PHYSICAL EXAMINATION: On physical exam he is afebrile with
vital signs stable. He was in no apparent distress. His
lungs were clear to auscultation bilaterally. His heart was
regular rate no murmurs rubs or gallops. His abdomen was
soft nontender nondistended with normoactive bowel sounds.
Incision was clean dry and intact.

LABORATORIES: His white count was 4.9 hematocrit of 43.7
platelet count of 182. Urinalysis was negative.
Chemistries DISEASE : Sodium was 134 potassium 3.9 chloride of 102
bicarb of 26 BUN 18 creatinine of 1.3 blood sugar of 108
CK of 72 troponin was less than 0.3.

He had a CTA to rule out pulmonary embolus DISEASE which was negative
and a chest x-ray which showed no pneumonia DISEASE and only some
mild atelectasis DISEASE .

Patient was admitted to the Intensive Care Unit for
monitoring and planned evaluation. Upon admission to the
Emergency Room he had a temperature spike to 104 with fevers DISEASE
and chills DISEASE . He had blood cultures done at that time which
ultimately grew nothing. He was started on broad-spectrum
antibiotics Vancomycin gentamicin and Flagyl and was
cultured.

On hospital day #2 he was changed to Vancomycin levo and
Flagyl and he continued to improve. His white count was
normal throughout his entire hospital admission. His
temperature max on hospital day #2 was 104.5. His primary
care doctor also saw him and suggested a lower extremity
ultrasound to rule out DVT DISEASE which was done and was negative.

His platelet count began to drop on [**7-6**]. His Heparin was
stopped and a HIT DISEASE antibody was sent which is pending at the
time of discharge.

.............. was consulted for evaluation of mastoids. A
head CT scan was done on [**2155-7-6**] which showed fluid in his
left mastoid air cell. It was felt that this was unlikely
cause of his fevers DISEASE and is instructed to followup the [**Hospital **]
Clinic if necessary.

Patient was transferred to the floor on [**2155-7-6**] and was
stable. On hospital day #4 his temperature which had been
the highest at 104.5 was down to 100.4 and he continued to
do well. He was allowed to eat a regular diet. His platelet
count dropped again and his Vancomycin was stopped.

On [**2155-7-8**] his platelet count and white blood cell count
had elevated after his Heparin was stopped. His HIT DISEASE was
still pending at that time and the Vancomycin had been
stopped for a fear of his pancytopenia DISEASE .

On hospital day #5 he was afebrile now for 72 hours and it
was felt safe that he could be discharged home. He is
continued on levo/Flagyl for seven more days and instructed
to followup with Dr. [**Last Name (STitle) 957**] in [**2-6**] weeks as well as follow
up with his primary care physician.

PRESCRIPTION MEDICATIONS:
1. Protonix 40 mg po q day.
2. Theophylline sustained release 200 mg po q day.
3. Levofloxacin 500 mg po q day.
4. Flagyl 500 mg po tid.

DISCHARGE INSTRUCTIONS: Instructed to continue all of his
home medications as normal and patient was discharged home
in stable condition on [**2155-7-8**].

FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr.
[**Last Name (STitle) 957**] as well as his primary care doctor.

DISCHARGE DIAGNOSES:
1. Fever DISEASE now on antibiotics levofloxacin and Flagyl.
2. Pancytopenia DISEASE now off Heparin and resolving.
3. Prostate cancer DISEASE status post prostatectomy.
4. Hypertension DISEASE .
5. Left inguinal hernia DISEASE status post left inguinal hernia
repair.

CONDITION ON DISCHARGE: Stable.



[**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 4007**]

Dictated By:[**First Name (STitle) 4008**]
MEDQUIST36

D: [**2155-7-8**] 08:57
T: [**2155-7-8**] 08:59
JOB#: [**Job Number 4009**]
Admission Date: [**2181-7-17**] Discharge Date: [**2181-7-20**]

Date of Birth: [**2125-8-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
lisinopril

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
55M with history of HTN GERD DISEASE and asthma DISEASE presenting with 7 days
of worsening SOB and cough DISEASE productive of thick occasionally
brown sputum. Initially with sinus/congestion symptoms last week
which since resolved but now with respiratory symptoms. Has
been taking albuterol hfa/nebs without significant relief. He
takes fluticasone INH [**Hospital1 **] as control medicationAdmission Date: [**2131-10-20**] Discharge Date: [**2131-11-4**]

Date of Birth: [**2050-1-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Levofloxacin / Allopurinol

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Bilateral hip pain DISEASE

Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty
Right hip ORIF
Intubation
PICC placement


History of Present Illness:
81 yo woman with PMH signficant for SLE gout CHF DISEASE and MVR
severe osteoporosis DISEASE who was admitted on [**2131-10-11**] to [**Location (un) **]
[**Location (un) 1459**] from NH c/o bilateral hip pain DISEASE . She denied trauma DISEASE but
had an overlying hematoma DISEASE on the right side however she does
not Admission Date: [**2132-8-3**] Discharge Date: [**2132-8-8**]

Date of Birth: [**2053-2-6**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Demerol / Lovastatin / Levaquin / Gentamicin / Iodine Containing
Agents Classifier

Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Increased sputum worsening SOB

Major Surgical or Invasive Procedure:
None

History of Present Illness:
79F Russian speaking hx of Pulmonary MAC DISEASE (Mycobacterium avium
complex diagnosed in [**2128**]) on standing clarithromycin
ethambutol and rifampin complicated by bronchiectasis DISEASE followed
by Dr. [**Last Name (STitle) 575**]. Who presents with worsening of breath cough DISEASE
and sputum production for 2 weeks worse over the last two days.
Patient reports increasing cough DISEASE productive of yellow/clear
sputum without associated fevers DISEASE or chills DISEASE . Confirms some
post-tussive pain DISEASE and occassional post-tussive nausea DISEASE . Patient
also denies night sweats however reports increased weight loss DISEASE
over the past months.
.
Of note patient recently seen [**Doctor Last Name 575**] in clinic on [**2132-7-29**]
and was started on Cefaclor one 500 mg capsule 3 x a daily for
a week for increasing sputum production although she has been
noncompliant due to nausea DISEASE and vomiting DISEASE . She has also been
unable to use Acupella as it gives her headache DISEASE . Patient had a
[**2132-7-29**] Chest CT Scan at the time that revealed generalized
progression of widespread small airway bronchiectasis DISEASE and
bronchiolitis DISEASE .
.
She returned to the ED on [**2132-8-3**] with increasing sputum
production and difficulty breathing. She has had this for 2
weeks. Vitals in the ED were 97.2 Labs were notable for WBC of
16 and sodium of 109 (baseline 135). She was given 1 dose of
CTX. CXR revealed worsening small airways disease DISEASE consistent
with patient's history of MAC.

Past Medical History:
1. Pulmonary MAC infection DISEASE with tree-in-[**Male First Name (un) 239**] opacities DISEASE and
bronchiectasis DISEASE now on antibiotics nearly continuously since
[**Month (only) 205**]
[**2128**]. Has been on triple therapy since [**2128**]
2. Significant head tremor DISEASE - worsened with albuterol & flovent
3. Lower airway colonization DISEASE with pseudomonas DISEASE .
4. Obstructive airways disease DISEASE .
5. Hypertension DISEASE .
6. GERD.
7. Weight loss DISEASE .
8. Headaches DISEASE .
9. Possible Levaquin and or Zithromax allergy DISEASE .
10. Hyperlipidemia DISEASE


Social History:
Denies alcohol or tobacco useAdmission Date: [**2132-8-26**] Discharge Date: [**2132-9-2**]

Date of Birth: [**2053-2-6**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Demerol / Lovastatin / Levaquin / Gentamicin / Iodine Containing
Agents Classifier

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
History of Present Illness: Patient is a 79 y/o Russian
speaking female with a hx of Pulmonary MAC DISEASE diagnosed in [**2128**] on
standing clarithromycin ethambutol and rifampin complicated by
bronchiectasis DISEASE who presented from home with worsening shortness
of breath cough DISEASE and sputum production for 2 days. Patient
reports that yesterday her breathing started becomming more
difficult with increased cough DISEASE productive of yellow/clear sputum
without associated fevers DISEASE or chills DISEASE . Her breathing improved
with clearing of her secretions however this morning she was
unable to produce any phlegm DISEASE and her breathing became much more
labored DISEASE . She presented to the ED due to worseing SOB. She
denies recent chest pain pleuritic pain nausea vomiting DISEASE or
diarrhea DISEASE . Per her husband she has had less energy and decreased
appetite since her last hospitalization however her breathing
had been stable until 2 days ago. Patient denies night sweats
however reports increased weight loss DISEASE over the past months.
.
Of note patient was recently admitted to [**Hospital1 18**] on [**8-3**] with
similar complaints. Imaging at that time showed progression of
widespread small airway bronchiectasis DISEASE and bronchiolitis DISEASE . She
was admitted to the ICU however did not require intubation or
steroids. She completed 5 days of cefepime per ID
recommendations and completed an additional 10 day course of
cefpodoxime 200mg po BID for presumed CAP.
.
In the ED VS initially showed T 96.7 BP 149/84 HR 89 RR 28-48 O2
sat 97% on RA DISEASE . CXR showed interval improvement in the
multifocal patchy opacities DISEASE previously noted. She was given one
dose of cefepime and ASA 325mg x1. She was placed on oxygen for
comfort and then desaturated into the 80's and was placed on NRB DISEASE
with inc. in her oxygen sat to 100% however she remained
tachypneic. Due to inability to wean off NRB she was admitted
to the ICU for further treatment.


Past Medical History:
1. Pulmonary MAC infection DISEASE with tree-in-[**Male First Name (un) 239**] opacities DISEASE and
bronchiectasis DISEASE now on antibiotics nearly continuously since
[**Month (only) 205**]
[**2128**]. Has been on triple therapy since [**2128**]
2. Significant head tremor DISEASE - worsened with albuterol & flovent
3. Lower airway colonization DISEASE with pseudomonas DISEASE - recently
completed course of cefepime/cefpodoxime (unclear how diagnosis
of colonization DISEASE made)
4. Obstructive airways disease DISEASE .
5. Hypertension DISEASE .
6. GERD.
7. Weight loss DISEASE .
8. Headaches DISEASE .
9. Possible Levaquin and or Zithromax allergy DISEASE .
10. Hyperlipidemia DISEASE


Social History:
Denies alcohol or tobacco useAdmission Date: [**2195-3-7**] Discharge Date: [**2195-3-11**]

Date of Birth: [**2148-5-10**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Abdominal pain hypothermia DISEASE

Major Surgical or Invasive Procedure:
1) Arterial line
2) Central venous line /femoral line
3) Patient continued his usual peritoneal dialysis sessions


History of Present Illness:
Mr. [**Known lastname 122**] is a 46 year-old male with HIV Hepatitis B/C ESRD DISEASE
on peritoneal dialysis who presented to the ED with abdominal
pain constipation DISEASE and also feeling dizzy with lightheadedness.
Called the ambulance for these symptoms. Initial VS 91.1F
orally HR 72 BP initially unmeasurable RR 20 and 100% oxygen
saturation on room air. Exam with clear lungs RRR distended
abdomen which was soft and full. He refused a rectal exam. CT
was obtained given abdominal pain DISEASE and preliminary read was
negative for any acute intrabdominal processes. Right femoral
line was placed with some difficulty due to scar tissue. BP
remained difficult to assess given severe vascular disease DISEASE .
Repeat VS soon after presentation revealed temperature 96.1F
75HR BPs of 59/25-105/47 RR 12 and oxygen saturation was 100%
room air. Fingerstick glucose was 123. Patient had potassium
repleted with 40 mEq K in 1L NS with 3 additional L NS. His
peritoneal dialysate was sampled and did not reveal evidence of
infection DISEASE . Denies ever having abdominal pain DISEASE but more a sense
of constipation DISEASE and Admission Date: [**2132-9-4**] Discharge Date: [**2132-9-9**]


Service: MED

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
1. SOB x 1 week
2. intermittent black stool for 6 months

Major Surgical or Invasive Procedure:
Upper Endoscopy
Colonoscopy


History of Present Illness:
This is an 80 yo F who presents to the ED with SOB and LE edema DISEASE
x1 week. On arrival to the ED she was unable to speak in full
sentences and was wheezing DISEASE . On further questioning she claims
that she had not been taking her usual dose of lasix for one
week. Her presciption had ran out.
She also notes a 6 month history of intermittent black stool.
She has discussed this with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Her most recent
occult blood in [**2132-8-20**] was negative and according to Dr. [**Last Name (STitle) **]
the stool was brown not black as she describes it. Patient also
claims that she has occasional BRBPR on straining with BMs with
a history of hemorrhoids DISEASE . She is on a daily ASA and denies
other NSAID use. She has no history of alcohol consumption.
Denies abd pain/nausea/vomitting/hemetemesis.
On ROS she denies chest pain/fever/ chills/changes in bowel
habit/headache/hemeturia/changes DISEASE in diet.


Past Medical History:
1. DM II
2. HTN DISEASE
3. pulmonary hypertension DISEASE
4. increased cholesterol
5. chroninc low back pain DISEASE and sciatica DISEASE


Social History:
Denies ETOH IVDA or tob use.

Physical Exam:
BP 150/58 P70
Gen: comfortable pale elderly Russian speaking female lying in
bed in NAD.
HEENT: PERRL. Anicteric. MMM. Pale conjunctiva
Neck: Supple. No masses or LAD. JVD 8-10 cm.
Lungs: diffuse crackles.
Cardiac: RRR. S1/S2. II/VI systolic M heard best at apex.
Abd: Soft obese NT ND Admission Date: [**2197-5-16**] Discharge Date: [**2197-5-19**]

Date of Birth: [**2148-5-10**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypothermia DISEASE altered mental status

Major Surgical or Invasive Procedure:
none

History of Present Illness:
49M with HBV HCV and ESRD DISEASE [**1-11**] HIV on dialysis for 25 years
presents with purulent drainage from around the peritoneal
dialysis catheter with an exposed cuff. He dialyzes himself at
home and follows up at [**Hospital 4029**] Clinic sporadically. He presented
to [**Hospital 4029**] Clinic today and was sent to [**Hospital1 18**] ED for the exposed
catheter cuff and exit site infection DISEASE . The peritoneal dialysis
catheter is working and he reports clear output.

The patient denies fevers chills nausea DISEASE vomitting abdominal
pain diarrhea DISEASE . He does not recall last bowel movement DISEASE . He
reports decreased appetite and weight loss DISEASE but unsure how much.
He was dialyzed last night.

The patient is a very poor historian. There is a note in his
paperwork from [**Last Name (un) 4029**] that he was admitted to [**Hospital1 336**] from [**2197-5-4**]
to [**2197-5-9**] but it does not state why. The patient reports that
it was for infection DISEASE of his peritoneal dialysis catheter and he
was treated with antiobiotics.

On initial evaluation in the ED the patient was reportedly very
somnolent and unresponsive to sternal rub but then aroused
without intervention and was able to answer questions. CD4
count was 273 2 years ago and the patient is reportedly
non-compliant with his medications.

Past Medical History:
* HIV
- diagnosed HIVAdmission Date: [**2195-10-31**] Discharge Date: [**2195-11-4**]


Service: NEUROLOGY

HISTORY OF PRESENT ILLNESS: [**Known firstname 4036**] [**Known lastname **] is a 58 year-old
right handed male with a past medical history significant for
presented to the Emergency Department on [**2195-10-30**] in the
evening complaining of acute onset of left sided weakness.
The patient reports that he had been sitting on his couch at
11:30 p.m. on the 23rd when he suddenly felt lightheaded and
dizzy. He did not really feel that he was particularly weak
or numb DISEASE on one side or the other. He denied any headache DISEASE or
changes in vision at that time. His family however noted
On arrival to the Emergency Department he was evaluated and
noted to be dysarthric and he had mild left face arm and leg
weakness DISEASE and left sided neglect DISEASE . An acute MRI revealed subtle
DWI changes in the right lenticulo- striate arterial territory
suggestive of early ischemia DISEASE . A MRA showed possible mild stenosis
of the distal M1 segment. While in the MRI scanner his weakness
clearly became worse. He was given TPA at 1:43 a.m. This
did not seem to improve his clinical examination. He was
kept for observation in the Neurology Intensive Care Unit.
His course there was uneventful. He was transferred to the floor
on the 25th.

On exam on the neurology floor:

BP was 130/75 HR 74 RR 14

He was AO x 3
On CN exam had a right lower face weakness
Motor was 1-2/5 in the right arm and
3-4/5 in the lower extremity
DTR were [**Name2 (NI) 4037**]
Positive Babinski DISEASE 's sign on the right



Hospital course
The patient underwent a carotid ultrasound which showed no
significant stenosis DISEASE in the right or left carotid arteries.
The patient also underwent a transthoracic echocardiogram
which showed excellent left ventricular ejection fraction
greater then 55% and no potential source for embolus DISEASE . The
patient was evaluated by physical therapy and occupational
therapy and decided the best place for him to be discharged
to was acute rehabilitation. At the time of discharge the
patient was almost completely paretic in the left upper
extremity. He still had a left facial droop DISEASE and had regained
some function in his left lower extremity.
Of significance the patient was started on aspirin 81 mg po q
day and Aggrenox one tab po b.i.d. on the 25th.

DISCHARGE MEDICATIONS: In addition to the aspirin and
Aggrenox Lipitor 10 mg po q day insulin as the patient is a
diabetic DISEASE .

The patient will be discharged on a ground solid thin liquid
diet as per speech and swallow. The patient needs to follow
up in [**Hospital 4038**] Clinic in one months time.


[**Name6 (MD) 725**] [**Name8 (MD) 726**] M.D. [**MD Number(1) 727**]





Dictated By:[**Last Name (NamePattern1) 4039**]
MEDQUIST36

D: [**2195-11-4**] 11:53
T: [**2195-11-4**] 11:56
JOB#: [**Job Number 4040**]


Admission Date: [**2187-12-24**] Discharge Date: [**2187-12-28**]

Date of Birth: [**2108-9-21**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain lightheadedness DISEASE and dsypnea on exertion

Major Surgical or Invasive Procedure:
[**2187-12-24**] - Aortic valve replacement (21mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**]
tissue valve)/Coronary artery bypass grafting x 1 (Left internal
mammary artery-Admission Date: [**2156-8-1**] Discharge Date: [**2156-8-12**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 358**]
Chief Complaint:
epigastric/chest pain DISEASE

Major Surgical or Invasive Procedure:
ERCP with stent placement no sphincterotomy seconary to
supratheraputic INR

History of Present Illness:
HPI: 87yo man with h/o CAD s/p CABG [**2141**] mult PCI since
ischemic CMY with LVEF 35% Afib DISEASE on coumadin possible AS and/or
MR diet controlled DM2 DISEASE Admission Date: [**2171-9-26**] Discharge Date: [**2171-10-1**]

Date of Birth: [**2095-11-14**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 12**]
Chief Complaint:
sdfsda

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Known lastname 4048**] is a 75 y.o. female with pertinent history of MDS x 2
years chronic anemia DISEASE requiring blood transfusions (last
transfusion 1 wk prior to admission) and recent admission for
melanotic stools w/ neg GI workup. Pt was recently discharged
[**9-16**] from [**Hospital1 **] following admission for GIB DISEASE and subsequent
stabilization w/o intervention. Following discharge reports that
she was feeling tired and weak with decreased appetite. Admission Date: [**2114-4-3**] Discharge Date: [**2114-4-13**]

Date of Birth: [**2047-10-15**] Sex: M

Service: Cardiac Surgery

CHIEF COMPLAINT: Unstable angina DISEASE .

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 23**] is a 66-year-old
male with a past medical history of coronary artery disease DISEASE
type 2 diabetes mellitus hypertension DISEASE and
hypercholesterolemia DISEASE who came to [**Hospital1 190**] with unstable angina DISEASE .

He was in his usual state of health and doing well with
cardiac rehabilitation until about one week ago when he had
two episodes of chest pain DISEASE . He cardiologist had increased
his Zestril from 2.5 mg to 5 mg and his atenolol to 150 mg
p.o. q.d. The patient continued with cardiac rehabilitation
until the a.m. of admission (which was [**2114-4-3**]) when
he had two episodes of resting angina DISEASE at 1:15 a.m. and at
3 a.m. relieved by one sublingual nitroglycerin. He was
referred to cardiac catheterization for his unstable angina DISEASE .

PAST MEDICAL HISTORY: (His past medical history includes)
1. Coronary artery disease DISEASE . He had a cardiac
catheterization in [**2113-12-19**] with percutaneous
transluminal coronary angioplasty and stent of the left
anterior descending artery and the first obtuse marginal. He
had a catheterization in [**2114-1-19**] with percutaneous
transluminal coronary angioplasty of first obtuse marginal
in-stent stenosis DISEASE and subsequent brachy treatment with stents
placed distal and proximal to the first obtuse marginal.
2. Type 2 diabetes DISEASE mellitusAdmission Date: [**2114-4-3**] Discharge Date: [**2114-4-13**]

Date of Birth: [**2047-10-15**] Sex: M

Service: Cardiac Surgery

CHIEF COMPLAINT: Unstable angina DISEASE .

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 23**] is a 66-year-old
male with a past medical history of coronary artery disease DISEASE
type 2 diabetes mellitus hypertension DISEASE and
hypercholesterolemia DISEASE who came to [**Hospital1 190**] with unstable angina DISEASE .

He was in his usual state of health and doing well with
cardiac rehabilitation until about one week ago when he had
two episodes of chest pain DISEASE . He cardiologist had increased
his Zestril from 2.5 mg to 5 mg and his atenolol to 150 mg
p.o. q.d. The patient continued with cardiac rehabilitation
until the a.m. of admission (which was [**2114-4-3**]) when
he had two episodes of resting angina DISEASE at 1:15 a.m. and at
3 a.m. relieved by one sublingual nitroglycerin. He was
referred to cardiac catheterization for his unstable angina DISEASE .

PAST MEDICAL HISTORY: (His past medical history includes)
1. Coronary artery disease DISEASE . He had a cardiac
catheterization in [**2113-12-19**] with percutaneous
transluminal coronary angioplasty and stent of the left
anterior descending artery and the first obtuse marginal. He
had a catheterization in [**2114-1-19**] with percutaneous
transluminal coronary angioplasty of first obtuse marginal
in-stent stenosis DISEASE and subsequent brachy treatment with stents
placed distal and proximal to the first obtuse marginal.
2. Type 2 diabetes DISEASE mellitusAdmission Date: [**2117-2-15**] Discharge Date: [**2117-2-21**]

Date of Birth: [**2047-10-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Tetracyclines / Niacin

Attending:[**Location (un) 1279**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
cardiac catheterization

History of Present Illness:
THis is a 69yo M with h/o CAD DM2 DISEASE and HTN DISEASE who presented to the
ED with chest pain DISEASE . He woke up at 4am on the day of admission
with left sided sharp 10/10 chest pain DISEASE that radiates down his
left arm. He took nitro with minimal relief.On route to [**Hospital1 18**] on
the ambulance he recieved multiple [**Last Name (un) 4070**] spray which brought
the pain DISEASE down. He complained of nausea DISEASE but denies
SOB/palpitation/dizziness.
On arrival to ED his SBP is 180 with HR 90. He recieved ASA
lopressor morphine nitro gtt integrillin and plavix.
Concerning with in stent thrombosis DISEASE

Past Medical History:
1. coronary artery disease-CABG [**2113**]Admission Date: [**2120-10-7**] Discharge Date: [**2120-10-19**]

Date of Birth: [**2047-10-15**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Tetracyclines / Niacin

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**2120-10-8**] Redo sternotomy Aortic Valve replacement(21mm
[**Company 1543**] Mosaic Ultra porcine) Coronary artery bypass graft x
1(SVG-PDA)

History of Present Illness:
Known coronary artery disease DISEASE in 72 year old diabetic DISEASE . He has
had progressive dyspnea DISEASE and arm pain DISEASE with exertion for months.
Catheterization in [**Month (only) **] revealed critical aortic stenosis DISEASE
([**Location (un) 109**] 0.7cm2) with patent LIMA to LAD 30% lesion of radial
artery to ramus graft and an osteal 60% RCA stenosis DISEASE . The vein
graft to the obtuse marginal was occluded. He is admitted now
for valve replacement and possible coronary graft. His Coumadin
was stopped recently and he was admitted for Heparin therapy
preoperatively.

Past Medical History:
insulin dependent diabetes mellitus DISEASE
diabeteic neuropathy DISEASE
hypothyroidism DISEASE
lumbar disc disease DISEASE
paroxysmal atrial fibrilation
obesity DISEASE
s/p coronary artery bypass grafting
s/p tonsillectomy
hypertension DISEASE
dyslipidemia DISEASE
hearing loss DISEASE
benign prostatic hypertrophy DISEASE
degenerative joint disease DISEASE

Social History:
He lives with his wife in [**Name (NI) 620**].
Rare alcohol use and denies any cigarette smoking.
He is a retired pharmacist.

Family History:
Coronary artery disease DISEASE NegAdmission Date: [**2123-11-10**] Discharge Date: [**2123-12-3**]

Date of Birth: [**2047-10-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit
Extracts / Nafcillin / cefazolin

Attending:[**Doctor First Name 3298**]
Chief Complaint:
fever rigor vomiting DISEASE

Major Surgical or Invasive Procedure:
TEE [**11-12**] no vegetations EF 40-45%
DCCV: [**11-16**] converted to NSR
PICC line placed R arm
Temporary HD line placed R IJ [**2123-11-26**] removed [**2123-12-3**]

History of Present Illness:
Mr. [**Known lastname 23**] is a 76 yo M with h/o CAD CHF DISEASE a-fib AVR DM HTN
HLD p/w one day of fever DISEASE rigor nausea DISEASE and vomiting DISEASE . Pt felt
sudden onset rigor one day ago with fever DISEASE to 100 and BP
reportedly to 220/120 at home. He had some valium and was able
to sleep. He Of note pt did not have recent sickness no
weight loss DISEASE night sweats DISEASE . He did report some exercise
intolerance recently in the gym which he attributed to
hypoglycemia DISEASE . Of note pt had a PCI with 2 drug eluting stents
placed in LAD and R-PDA. Pt had no recent dental work and never
had colonoscopy.

Pt went to [**Hospital1 **] [**Location (un) **] today where he had VS: 102.1 HR: 101 BP:
123/49 Resp: 23 O(2)Sat: 100%. Lab showed WBC of 11.3 with 7%
Bands INR 3.2 Cr 2.4 CK 1400 CK-MB 6 Trop 0.035Admission Date: [**2134-2-16**] Discharge Date: [**2134-3-9**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
syncope DISEASE

Major Surgical or Invasive Procedure:
R humeral ORIF
Cervical laminectomy


History of Present Illness:
This is a 81 year old Russian speaking only woman brought from
home after a syncopal DISEASE episode on day of admission. Through
Russian interpreter patient states that she had an episode of
chest pain DISEASE and shortness of breath DISEASE after lunch and then thinks
she passed out. Patient woke up with a forehead laceration DISEASE and
right forearm swelling.
.
In ED GCS DISEASE 15 AOx4 FS 130. Patient denied chest pain DISEASE or
shortness of breath DISEASE . EKG showed coarse afib vs atach with 2:1
block without no acute ischemic changes. Head CT was negative
for intracranial hemorrhage DISEASE and no new c-spine fracture DISEASE on
C-spine DISEASE . Hip films show no definite fracture DISEASE . Right arm x-ray
negative for fracture DISEASE . CTA to rule out PE in setting CP and
syncope DISEASE . [**First Name3 (LF) 1957**] was consulted. Patient rec'd IV morphine and a
tetanus DISEASE shot in ED.


Past Medical History:
1. DM II
2. HTN DISEASE
3. pulmonary hypertension DISEASE
4. increased cholesterol
5. chronic low back pain DISEASE and sciatica DISEASE


Social History:
Patient lives alone. She does not have any stairs at home and is
not able to do stairs and does find that the symptoms are
somewhat worse with prolonged sitting. Patient wears a back
support corset(belt) compression stocking and uses a walker.

Family History:
NC

Physical Exam:
INITIAL EXAM DISEASE ON MEDICINE SERVICE
97.0 139/58 57 19 96% room air
GEN: mild distress lying on back in hard collar
HEENT: 2cm laceration on forehead PERRL EOMI tongue no bite
marks laterally slight bruise on tip
CV: irregular rate nl S1 S2 II/VI holosystolic murmur DISEASE at LLSB
no gallops
PULM: CTA anteriorly/laterally wheeze
ABD: obese soft nontender nondistended Admission Date: [**2124-1-20**] Discharge Date: [**2124-1-25**]

Date of Birth: [**2047-10-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit
Extracts / Nafcillin / cefazolin

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Renal Failure/pneumonia DISEASE

Major Surgical or Invasive Procedure:
PICC line placement.


History of Present Illness:
76M complicated past medical history including CAD status post
CABG s/p stents [**Month (only) **]/[**2122**] (on aspirin and plavix) status post
biologic AVR CHF DISEASE with EF 35-40 % paroxysmal atrial
fibrillation DISEASE on coumadin (now off secondary to recent epistaxis DISEASE
requiring blood transfusion) history of strokes CKD DISEASE (baseline
Cr 2.5) with recent kidney injury DISEASE thought to be secondary to AIN DISEASE
from naficllin requiring hemodialysis now off. He presented to
[**Hospital1 **] with lethargy DISEASE . Patient states that he awoke this
morning feeling unwell. He had no specific or localizing signs.

He was recently discharged from [**Hospital3 4103**] on the [**Hospital **] Rehab
Facility 3 days prior to presentation. He had been there since
an admission to [**Hospital1 18**] for MSSA bacteremia DISEASE complicated by what
appears to be acute kidney injury DISEASE from acute interstitial
nephritis DISEASE thought to be secondary to nafcillin. He also
developed diffuse skin vasculitis DISEASE at that time. He had been on
steroids which had been tapered to off about 2 weeks ago. He
has also had intermittent delirium DISEASE and volume overload DISEASE . It
appears an NSTEMI also complicated his course.

He had an episode of epistaxis DISEASE for which he was admitted to
[**Hospital1 **] from [**1-1**] to [**1-3**] with an INR greater than 10 at the
time. He is no longer on Coumadin but he is on aspirin and
Plavix. He has had no further bleeding DISEASE . He has also had recent
transaminitis DISEASE thought to be secondary to amiodarone and statin.
He had had a right upper quadrant ultrasounds which did not
reveal acute cholecystitis DISEASE but did show gallstones DISEASE in the
gallbladder. His amiodarone has been discontinued but it
appears he is back on his simvastatin.

At [**Hospital1 **] the patient complained of pain DISEASE in his penis from
Foley catheter insertion in the emergency department.

He denies shortness of breath fever chills abdominal pain DISEASE
nausea vomiting diarrhea chest pain DISEASE . He notes a mild
nonproductive cough DISEASE over the last few days. He reports his
white blood cell count has been elevated intermittently in the
past. It was elevated at NewBridgeAdmission Date: [**2124-2-12**] Discharge Date: [**2124-2-16**]

Date of Birth: [**2047-10-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit
Extracts / Nafcillin / cefazolin

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
A-line placement

History of Present Illness:
76 y/o male with sCHF (EF 35-40%) AS s/p biologic AVR CAD
pAF DMII c/b neuropathy hypothyroidism DISEASE and stage III/IV CKD DISEASE
with a recent admission for [**Female First Name (un) 564**] fungemia DISEASE who presented from
[**Hospital1 **] [**Location (un) 620**] with SOB and altered mental status. He was recently
hospitalized at [**Hospital1 18**] from [**Date range (1) 4108**] with [**Female First Name (un) 564**] fungemia DISEASE
(no evidence of endophthalmitis DISEASE and TEE without evidence of
Endocarditis DISEASE ) with a hospital course complicated by a left IJ
DVT DISEASE (for which he was bridged to Coumadin with Heparin) acute
on CKD ( CKD DISEASE [**1-20**] AIN DISEASE most likely [**1-20**] Nafcillin with baseline
creatinine of Admission Date: [**2166-4-11**] Discharge Date: [**2166-4-18**]

Date of Birth: [**2119-11-6**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Penicillins / Egg / Sulfa(Sulfonamide Antibiotics) /
Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache DISEASE

Major Surgical or Invasive Procedure:
cerebral angiogram

History of Present Illness:
This is a 46 year old woman who was a passenger on a
motorcycle this evening when she developed severe headache DISEASE at
the
vertex that she describes as the worst headache DISEASE of her life. She
was taken to OSH and CT showed SAH DISEASE . She was transferred to [**Hospital1 18**]
for further management

Past Medical History:
AIDS DISEASE (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4109**] [**Hospital 1559**] Medical Center)
Hepatitis C DISEASE CD4 in 20's viral load 190000 thrombocytopenia DISEASE
recently seen by Hem/Onc at OSH depression hypertension DISEASE
ureteral implants colposcopy IV drug use rotator cuff injury
gallstones DISEASE

Social History:
She formally used IV drugs reports no current ETOH.
Reports 3 cigarettes for 1 year. She lives in a sober house. She
is on disability.


Family History:
No aneurysms DISEASE


Physical Exam:
On Admission:
: T:98.7 BP: 145/99 HR: 70 R 24 O2Sats 100% 2L NC
Gen: WD/WN uncomfortable photophobic.
HEENT: Pupils: [**2-19**] EOMs intact
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Awake but lethargic somewhat uncooperative with
exam. Yelling at examiner.
Orientation: Oriented to person place and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria DISEASE or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light 2 to 1
mm bilaterally.
III IV VI: Extraocular movements DISEASE intact bilaterally without
nystagmus DISEASE .
V VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX X: Palatal elevation DISEASE symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius DISEASE normal bilaterally.
XII: Tongue midline without fasciculations DISEASE .

Motor: Normal bulk and tone bilaterally. No abnormal movements DISEASE
tremors DISEASE . Patient not cooperative with exam due to HA moving
symmetrically. No pronator drift

Sensation: Intact to light touch

Toes downgoing bilaterally
on the day of discharge:
[**2166-5-19**]- deceased


Pertinent Results:
CTA head [**2166-4-11**]
CT angiography of the head demonstrates an
approximately 3.5 mm aneurysm DISEASE arising from the anterior
communicating artery at the junction of the right A1 and A2
segments and pointing to the left side. No other definite
aneurysms DISEASE are identified in the arteries of anterior and
posterior circulation.

IMPRESSION:
1. CT head demonstrates subarachnoid and intraventricular blood
and signs of early obstructive hydrocephalus DISEASE .
2. CT angiography of the head demonstrates a 3.5 mm aneurysm DISEASE
from the
anterior communicating artery at the junction of the right A1
and A2 segment and pointing to the left side. No other aneurysms DISEASE
are seen in the head.
3. CT angiography of the neck demonstrates no vascular occlusion DISEASE
or stenosis.

CT Head [**2166-4-12**]:
IMPRESSION:
1. Status post coiling of ACOM aneurysm DISEASE . Stable amount of
subarachnoid
hemorrhage DISEASE with interval redistribution. Minimal interval
increase in the
left lateral ventricle IVH.
2. Diffuse sulcal effacement as before likely secondary to
mild global
edema DISEASE .
3. No new hemorrhage DISEASE .

ECHO [**2166-4-14**]:
The left atrium is mildly dilated. No atrial septal defect DISEASE is
seen by 2D or color Doppler. Left ventricular wall thickness
cavity size and regional/global systolic function are normal
(LVEF Admission Date: [**2149-11-5**] Discharge Date: [**2149-11-20**]

Date of Birth: [**2076-10-17**] Sex: F

Service: SURGERY

Allergies DISEASE :
Sulfa (Sulfonamides) / Flagyl

Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Mental decline
Abnormal gait
Slurred Speech

Major Surgical or Invasive Procedure:
None

History of Present Illness:
73F with programmable VP shunt for normal pressure hydrocephalus DISEASE
with noted decline in cognitive function since [**Holiday 1451**] to
include episodes of left arm weakness/numbness slurred DISEASE speech
and altered vision/hearing.

Past Medical History:
Crohn's disease DISEASE
Breast cancer DISEASE (Admission Date: [**2191-8-22**] Discharge Date: [**2191-9-3**]

Date of Birth: [**2123-11-18**] Sex: M

Service: CCU/[**Doctor Last Name 1181**]/MEDICINE

CHIEF COMPLAINT: Cardiac arrest DISEASE and unresponsiveness.

HISTORY OF PRESENT ILLNESS: The patient is a 67 year old man
with no cardiac history who had flu like symptoms for several
days and was at [**Location (un) **] on [**2191-8-22**] to purchase over
the counter medicines. The staff there observed that he
appeared sick. He had a syncopal DISEASE episode and by-standers
initiated CPR. It is unclear how long he was down.

When the EMTs arrived he was asystolic DISEASE . He was intubated
and given Epinephrine. He was in pulseless DISEASE electrical arrest
which converted to sinus rhythm after five minutes. He was
brought to [**Hospital3 **] where he was unresponsive and head
CT was negative for bleed DISEASE .

He was transferred to [**Hospital1 69**]
[**2191-8-22**] for cardiac catheterization which showed clean
coronary arteries with ejection fraction of 41%Admission Date: [**2163-7-19**] Discharge Date: [**2163-7-23**]

Date of Birth: [**2091-3-10**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Codeine / Penicillins

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**2163-7-19**] - Ministernotomy with Primary ASD DISEASE closure


History of Present Illness:
This is a 72-year-old female who has shortness of breath DISEASE on
exertion. Her work-up revealed an atrioseptal defect of the
secundum type of left and right shunting and elevated right
heart pressures. It was recommended that she have this repaired.
The risks were explained to her and she agreed to proceed with
operation to close her atrioseptal defect.


Past Medical History:
1. HTN DISEASE
2. Hypothyroidism DISEASE
3. Atrial fibrillation DISEASE s/p ablation [**3-23**]
4. ASD secundum type DISEASE with left to right shunting on echo
Echo [**12-3**] (TEE): nl LA size no thrombus mod dilated RAAdmission Date: [**2137-8-23**] Discharge Date: [**2137-8-27**]

Date of Birth: [**2072-2-17**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Zestril / Statins-Hmg-Coa Reductase Inhibitors

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain DISEASE

Major Surgical or Invasive Procedure:
[**2137-8-23**] Coronary artery bypass grafting x2 with
left internal mammary artery graft left anterior descending
reverse saphenous vein graft to the posterior descending
artery.


History of Present Illness:
65 year old male with exertional chest pain DISEASE and positive stress
test recently found to have severe three vessel coronary artery
disease. He is scheduled
for surgical revascularization on [**2137-8-23**].

Past Medical History:
Hypertension DISEASE
Dyslipidemia DISEASE
[**First Name8 (NamePattern2) **] [**2136-1-10**]
Glucose Intolerance
Varicose Veins DISEASE
Erectile Dysfunction DISEASE
Right Shoulder Pain DISEASE
History of Bells Palsy DISEASE
s/p Vein DISEASE Stripping of Right GSV
s/p Left Groin Lipoma DISEASE s/p surgery radiation [**2105**]

Social History:
Occupation: Cook at hotel
Lives with: wife
[**Name (NI) **]: Asian
Tobacco: quit 30 yrs agoAdmission Date: [**2122-5-30**] Discharge Date: [**2122-6-8**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Respiratory failure/sepsis

Major Surgical or Invasive Procedure:
MICU stay [**2122-5-30**]-Admission Date: [**2172-2-12**] Discharge Date: [**2172-2-18**]

Date of Birth: [**2088-9-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Vancomycin

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
hypotension DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is an 83 y.o male with a history of MDS HTN gout CVA DISEASE
afib CHF colon cancer DISEASE s/p colectomy with ostomy who initially
presented to [**Location (un) 620**] with weakness DISEASE and chills DISEASE . There he was
found to have an elevated WBC from baseline decreased platelet
counts and positive UA.
.
In the emergency department his initial vitals were VS at [**Telephone/Fax (2) 4146**]00/63 18 98%. Here he was noted to have guaiac
positive brown stool from ostomy blood near stoma. During his
stay in the ED his SBP was running in 90's. He received a
total of 2L IVF. He was found to have questionable ischemic vs.
emboli to the finger. Vascular surgery was consulted who
believed this to be consistent with bruising DISEASE no concern for
ischemia DISEASE . EKG shows STD laterally trop .05 he did not receive
an aspirin. CXR unremarkable. The patient had 3 PIVs placed.
He was given ceftaz and linezolid empirically as well as stress
dose steroids.
.
On arrival to the [**Hospital Unit Name 153**] the patient stated that his only concern
was left shoulder pain DISEASE for a few days-inside the joint some
radiation no paresthesias DISEASE or weakness. Pt's aid reported
increased diarrhea DISEASE and output from the stoma that Admission Date: [**2172-3-5**] Discharge Date: [**2172-3-8**]

Date of Birth: [**2088-9-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Vancomycin

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Chief Complaint: Leg pain DISEASE AMS hypotension DISEASE leukocytosis

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 4148**] is a 83 year old male with a history of MDS DISEASE CVAs
PVD CHF colon cancer DISEASE s/p iliostomy and recent C. difficile DISEASE
collitis DISEASE who presents with left leg pain DISEASE and altered mental
status was found to be relatively hypotensive DISEASE and have a
leukocytosis DISEASE .
.
Mr. [**Known lastname 4148**] was recently admitted to [**Hospital1 18**] on [**2-21**] and treated
for left leg pain DISEASE . His furosemide dose was decreased on that
admission and he began receiving weekly transfusions for his
end-stage MDS DISEASE . Per his family his bilateral lower extremity has
progressively worsened over the last couple of weeks and the
redness in his left lower leg has worsened significantly in the
last two days. Per family the patient's PCP increased the
patient's lasix to 20 mg daily yesterday. Per family Mr.
[**Known lastname 4148**] became unusually cantankerous the evening prior to
admission and this morning he was screaming at family asking to
have his legs taken off because of the pain DISEASE . He seemed somewhat
more confused as well. Last night he also had night sweats and
chills DISEASE . It is unclear if he was febrile DISEASE as a temperature was not
taken. He did not receive any of his morning medications this
morning and family brought him to the ED because of concern for
the leg pain DISEASE and possible sepsis DISEASE from his leg.
.
In the ED initial vs were: BP 106/54 HR 72 R 30 O2 sat 86%.
Patient was felt to globally appear unwell. Labs were notable
for a WBC count of 37.2 and lactate of 3.3. Chest x-ray was read
as no acute process. Patient was given cefepime 2g IV
levofloxacin 750 mg IV 500 cc NS a six pack of platelets and
morphine 1 mg IV x 5. He was ordered for blood but did not
receive it prior to leaving the ED. Vital signs on transfer were
BP 91/55 HR 100 98% on RA DISEASE RR 16.
.
On the floor the patient states that he feels terrible but is
unable to specify exactly why he feels so and initially denied
any pain DISEASE anywhere (specifically chest abdomen legs headache DISEASE ).
He denied any shortness of breath or nausea DISEASE . He was unable to
urinate but refused a catheter. Family states mental status is
still not normal but somewhat improved from earlier.
.
Review of sytems: (per family and patient)
(Admission Date: [**2134-8-12**] Discharge Date: [**2134-8-20**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
82yo Russian speaking F with a PMH of type II DISEASE DM HTN DISEASE
hyperlipidemia obesity pulmonary HTN DISEASE and anemia DISEASE who presented
to the ED this AM with worsening SOB x 2 weeks. Per the ED
resident the patient noted that she had had worsening SOB x 2
weeks (documented as 2 days [**Name8 (MD) **] RN note) and also complained of
orthopnea DISEASE and increasing lower extremity swelling DISEASE and weeping DISEASE
from a venous stasis ulcer DISEASE on her L shin. The patient was able
to communicate this verbally to ER resident (RN notes she was
only able to speak in 4 word sentences). Her VNA stated that she
was only 94% on 2L O2 at home and had rales [**12-28**] way up
bilaterally. On initial assessment in the [**Hospital1 18**] ER her vital
signs were T 98.2 BP 167/60 HR 61 RR 23 sats 100% on RA DISEASE . On
next assessment (2 hrs later) pt was felt to be very SOB while
attempting to use the bed pan. RN noted her to be dusky
diaphoretic. HR 72 RR 28 sats 90% on RA DISEASE . She was placed on a
NRB DISEASE with improvement in her O2 sats to 98%. BP rose to 210/74
then 215/93. CXR was taken and read as c/w pneumonia DISEASE . Blood cx
were obtained and ceftriaxone was administtered DISEASE . 90 mins later
she was felt to be diaphoretic again with increased work of
breathing. Her O2 sats dropped to 90% by NRB DISEASE and she was prepped
for intubation. She was given 2mg versed and was intubated. SBP
210 -Admission Date: [**2159-10-24**] Discharge Date: [**2159-11-10**]

Date of Birth: [**2090-1-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Losartan / Aspirin / Lisinopril-Hctz

Attending:[**First Name3 (LF) 4153**]
Chief Complaint:
pain DISEASE in left shoulder

Major Surgical or Invasive Procedure:
left shoulder hemiarthroplasty [**2159-10-24**]


History of Present Illness:
69 yo somalian woman with 6week old left hyumerous fx intial
presented 4weeks out from presumed injury while being transfered
to stretcher for dialysis came in to [**Hospital1 **] mc for shunt eval
fistogram showed left humerous fx because of left arm shunt dr
[**Last Name (STitle) **] felt that the only way could fix the humerous would
jepodize the shunt the patiebt who need the hemodaylisas access
switch to the rt side

Past Medical History:
1. Type 2 diabetes DISEASE
2. Diabetic nephropathy DISEASE
3. Status post left femur fracture DISEASE
4. Hyponatremia DISEASE
5. Hypercholesterolemia DISEASE
6. Unsteady gait
7. Cataracts DISEASE
8. Back pain DISEASE
9. Hypertension DISEASE
10. Anemia DISEASE of chronic disease DISEASE

Social History:
Lives with son who is very involved and well informed regarding
her care needs. Non smoker. No EtOH


Family History:
Noncontributory

Physical Exam:
heent wnl
chest exp rhochi decresaed bs
[**Last Name (un) **] rrr no mrg
abd sft nt nd
ext left arm swollen eccchymotic pain ful rom
neuro intact

Pertinent Results:
[**2159-10-24**] 03:12PM BLOOD WBC-12.1*# RBC-3.72* Hgb-10.5* Hct-33.6*
MCV-90 MCH-28.1 MCHC-31.1 RDW-20.7* Plt Ct-267
[**2159-10-24**] 03:12PM BLOOD Plt Ct-267
[**2159-10-24**] 03:12PM BLOOD Glucose-160* UreaN-29* Creat-3.7* Na-141
K-3.2* Cl-98 HCO3-30 AnGap-16
[**2159-10-24**] 01:20PM BLOOD Type-ART FiO2-50 pO2-212* pCO2-37
pH-7.58* calHCO3-36* Base XS-12 Intubat-INTUBATED
Vent-CONTROLLED
[**2159-10-24**] 02:51PM BLOOD Glucose-237* Lactate-2.7* Na-136 K-3.3*
Cl-99*
[**2159-10-24**] 01:20PM BLOOD Glucose-193* Lactate-1.5 Na-138 K-3.4*

Operative report ([**2159-10-24**]):
Service: ORT Date: [**2159-10-24**]

Date of Birth: [**2090-1-18**] Sex: F

Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **] [**MD Number(1) 4158**]

PREOPERATIVE DIAGNOSIS: Left proximal humerus fracture DISEASE .

POSTOPERATIVE DIAGNOSIS: Left proximal humerus fracture.

PROCEDURE: Left proximal humerus hemiarthroplasty DISEASE .

INDICATIONS: Mrs. [**Known firstname 4159**] [**Known lastname 4160**] is a 69-year-old female patient
with a complex medical history including end-stage renal
disease on dialysis diabetes DISEASE . She fell approximately 4 to 6
weeks ago sustaining a two-part proximal humerus fracture DISEASE
that has not healed. Over the last 2 weeks of her medical
admission to manage respiratory issues it was noted that the
flow from her arterial venous fistula DISEASE which is on the injured
side of her extremity was deficient. An angiogram was
obtained which demonstrated the presence of the humerus
fracture DISEASE . It is unclear when this fracture DISEASE occurred
presumably it could have occurred during transportation given
that the patient has no history of falling. The fracture DISEASE was
significantly displaced and
significantly angulated. The patient received alternative
hemodialysis access and the left upper extremity fistula was
left at this point unused in preparation for possible surgery
to address the humerus fracture DISEASE . the patient has so far not
develop any healing
or callus on films. I think this is not unusual given her
medical
history and
believe a repair of this 2-part humerus fracture DISEASE would
probably result in a non [**Hospital1 **] and I therefore believe that the
approach to address her fracture DISEASE instability surgically is to
perform a hemiarthroplasty. The family agrees and she now
presents for procedure.

PROCEDURE IN DETAIL: The patient was brought to the
operating room and after the successful induction of general
anesthesia was placed in the beach-chair position. The left
upper extremity was prepped and draped in the usual sterile
manner. Via the deltopectoral approach the fracture DISEASE was
exposed. There was significant soft tissue scarring but no
callous and there was good lateral
perfusion on the soft tissues which bleed DISEASE considerably. This
is secondary to the presence of the fistula DISEASE nearby.
Hemostasis was achieved with [**Last Name (un) 4161**] electrocautery. The
deltopectoral interval was found and the fracture DISEASE was
exposed. The humeral head lesser tuberosity and greater
tuberosity were osteotomized and preserved and the remaining
head was removed. The canal was exposed and reamed and
broached to accept a 12 mm Osteonics humeral prosthesis. A 21
mm humeral head was then selected and was found to give
appropriate fit and range of motion. At this point the canal
was irrigated. The final components were then brought to the
field and cemented with one bag of PMMA cement. The final
components were assembled and the lesser tuberosity and
greater tuberosity were repaired over the prosthesis using
the threaded holes in the prosthesis. The wound was
copiously irrigated and closed in layers with 0 PDS and 2-0
nylon over a drain. Dr. [**Last Name (STitle) 1005**] was present for the entire
procedure. All counts of sponges and instruments were
correct. C arm imaging was used at the end of the procedure to
establish the appropriate height and anatomy was restored.
The patient tolerated the procedure well and was taken to
recovery room without incident. Dr. [**Last Name (STitle) 1005**] was present for
the entire procedure.

CT head ([**11-2**]):

FINDINGS: There is no acute intra- or extra-axial hemorrhage DISEASE or
shift of normally midline structures. The ventricles cisterns
and sulci are somewhat prominent likely due to atrophic
changes. Again identified are scattered hypodensities within the
subcortical white matter consistent with small vessel ischemic
disease. A small area of decreased attenuation is identified
within the right basal ganglia consistent with prior lacunar
infarction DISEASE unchanged from prior studies. The [**Doctor Last Name 352**]-white matter
differentiation appears preserved. There has been interval
opacification of the mastoid air cells bilaterally. There is
minimal thickening of the right maxillary sinus. The visualized
soft tissues appear unremarkable.

IMPRESSION: No acute hemorrhage DISEASE . Evidence of chronic small
vessel ischemic disease DISEASE as well as prior lacunar infarcts DISEASE
unchanged.

[**11-8**] CT abd/pelvis
69 year old woman with diffuse persistent abdominal pain DISEASE s/p
PEA arrest DISEASE elevated lactate
REASON FOR THIS EXAMINATION:
Please evaluate for mesenteric ischemia DISEASE - angiogram protocol
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: Diffuse persistent abdominal pain DISEASE status post PEA
arrest with elevated lactate. Concern for mesenteric ischemia DISEASE .

CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Tiny (2 mm)
nodule seen within the left lower lobe not clearly visualized
at the time of the previous CT examinations. The visualized
portions of the heart and pericardium appear unremarkable. The
liver spleen and adrenal glands appear unremarkable.
Gallbladder contains a calcified stone in layering calcium
consistent with milk of calcium. There is stranding about the
inferior aspect of the pancreas within the mesenteric root. The
aorta is normal in caliber with mural calcifications DISEASE consistent
with atheromatous disease DISEASE . The kidneys appear atrophic
bilaterally. The large and small bowel loops are normal in
caliber. There is mucosal thickening within a short segment of
cecum. No other areas of abnormal bowel wall thickening DISEASE are
identified. There is no free intraperitoneal air and no free
fluid within the abdomen. There is no pathologic appearing
mesenteric or retroperitoneal lymphadenopathy.

CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The bladder
distal ureters rectum and sigmoid colon appear unremarkable.
There are uterine calcifications DISEASE . The uterus and adnexa DISEASE appear
otherwise unremarkable. There is no pathologic appearing pelvic
or inguinal lymphadenopathy DISEASE . There is diffuse stranding within
the subcutaneous tissues of the left buttock and right buttock
to a slightly less prominent degree. Multiple calcifications DISEASE are
seen within the soft tissues of the buttocks consistent with
injection granulomas DISEASE .

BONE WINDOWS: Bone windows demonstrate unusual contour of the
left femoral neck with bowing DISEASE and heterogeneous lucency within
the femoral neck and greater trochanter. No suspicious lytic or
sclerotic osseous lesions are identified.

MULTIPLANAR REFORMATS: Coronal and sagittal reformations
demonstrate a short segment of mucosal thickening within the
cecum.

IMPRESSION:
1. Short segment of mucosal thickening within the cecum finding
of uncertain significance. The differential diagnoses include
infectious inflammatory DISEASE or ischemic colitis DISEASE .
2. Peripancreatic stranding finding that could indicate
pancreatitis DISEASE . Clinical correlation is recommended.
3. Small bilateral pleural effusions DISEASE and bibasilar atelectasis DISEASE .
2 mm left lower lobe pulmonary nodule. If there is no history of
prior malignancy DISEASE this may be further evaluated by follow-up CT
in 1 year.
4. Cholelithiasis DISEASE and milk of calcium within the gallbladder.
5. Unusual configuration of the left femoral neck finding that
could suggest etiology such as fibrous dysplasia DISEASE


Brief Hospital Course:
ORTHOPEDIC SURGERY:
on [**2159-10-24**] she was admitted to the sda area anesthesia saw her
and had cocerns about her respiratory status and had a cxr done
it showed no pna and shecwas taken to the or and underwent a
left shoulder hemiarthroplasty transfered to pacu stable
* * * * * * * * * * * * * * * * * * * *
MEDICINE:
Patient was transferred to medicine on [**2159-10-26**]. The plan at
that time was for patient to recive hemodialysis and to
discharged home. While in hemodialysis patient became
hypotensive DISEASE . House officer was called. While attempting to get
an ABG patient had respiratory arrest DISEASE and a code blue was
activated. Patient was found to have pulseless DISEASE electrical
activity. Patient was successfully resuscitated and transferred
to the MICU. CTA was positive for pulmonary embolism DISEASE and
patient was started on Heparin. Her EKG had ST and ST
depressions laterally and Echocardiogram showed no evidence of
right heart strain. Her blood pressure stabilized and she was
transferred back to the floor on [**2159-10-29**]. The remainder of her
hospital course was characterized by persistent intermittent
episodes of hypotension DISEASE down to the 80's systolic. Measuring
blood pressure on Ms. [**Known lastname 4160**] is problem[**Name (NI) 115**] as she has a healing
surgical wound on her left arm and her right has poor
vasculature presumably from multiple past lines. She was
regularly hypotensive DISEASE (SBP 80's) during hemodialysis. Her blood
pressure responded well to 250 cc normal saline boluses.

Of note during this admission patient had one episode of
unresponsiveness. Patient was treated with narcan DISEASE with slight
improvement and aggressive electrolyte repletion (phosphate and
magnesium).) Vital signs were at her baseline throughout. No
acute changes on CXR or ECG. FSBG normal. Head CT negative.
She returned to baseline over the course of [**2-22**] hours and the
episode was attributed to excessive pain DISEASE medications and
multiple electrolyte abnormalities. The remainder of her
hospital course is organized by problem below:
.
#Anticoagulation: patient transitioned from heparin to coumadin
without incident. Still attempting to titrate to maintain INR
between [**2-22**]. Her INR on the date of discharge was
supratherapeutic. Her coumadin should be held on [**11-10**] and
re-started on [**11-11**] at 1 mg qhs IF her INR comes down to
therapeutic range (goal [**2-22**]).
.
#. Humeral Fracture DISEASE : Films were reviewed by orthopedic surgery.
No fracture DISEASE or damage to hardware during CPR evident on plain
film on [**2159-10-29**]. She will need follow up with orthopedics for
removal of stitches.
.
# Blood loss DISEASE - On two occaisions patient's hematocrit drifted
down. Neither could be entirely accounted for by surgery (per
ortho there was minimal blood loss DISEASE Admission Date: [**2159-12-5**] Discharge Date: [**2159-12-20**]

Date of Birth: [**2090-1-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Losartan / Aspirin / Lisinopril-Hctz

Attending:[**First Name3 (LF) 4162**]
Chief Complaint:
fever DISEASE

Major Surgical or Invasive Procedure:
Intubation for airway protection
tunneled line change over wire [**2159-12-18**]


History of Present Illness:
69 y/o female wtih PMH significant for ESRD DISEASE on HD type 2 DM
and recent PE resulting in PEA arrest DISEASE admitted through the ED
with sepsis DISEASE of unknown etiology. Pt was recently admitted to
[**Hospital1 18**] from [**11-16**] thorugh [**11-23**] with hypotension DISEASE thought to be
secondary to overdiuresis at HD. However a septic DISEASE component to
the hypotension DISEASE was also considered as the pt was found to have
citrobacter in her urine and C diff in her stool. Pt was then
discharged to [**Hospital1 100**] Senior Life where she was in her normal
state of health until three days ago. Her son reports that she
then developed a headache DISEASE and fevers DISEASE started three days ago
which were treated with tylenol. Then this morning she
developed fatigue DISEASE and did not eat well. He son also notes that
she appeared to be working hard to breath. She was found to be
febrile DISEASE to 101.9 and received levoflox and vancomycin. Pt was
then sent to the [**Hospital1 18**] ED for further evaluation. Per notes pt
denied SOB CP and abdominal pain DISEASE prior to intubation. She did
complain of a left frontal headache.
.
In the ED the pt's VS were singificant for a fever DISEASE of 103.8
tachycardia DISEASE in the 130s-150s and initial hypertensive DISEASE in the
140s. Her oxygen saturation was 96% on RA DISEASE but she was tachypneic
to 31. She was obtunded and was thus intubated for airway
protection. Post-intubation the pt's BP acutely dropped to
58/19 in the setting of propofol. When this medication was
discontinued her BP came back up to the 70s-90s/30s-50s. Pt was
then initiated on the sepsis DISEASE protocol. In the ED she received
vancomycin levofloxacin flagyl and cefepime (2 gm). She
received a total of 4 liters of NS then was started on levophed
for continued hypotension DISEASE . Pt is now transferred to the [**Hospital Unit Name 153**] for
further care.
.
Per pt's son she is bedbound at baseline due to her multiple LE
femur fractures DISEASE .

Past Medical History:
1. Type 2 diabetes mellitus DISEASE
2. Diabetic nephropathy DISEASE resulting in ESRD DISEASE for which she is on
HD. Pt was due for HD DISEASE but missed it secondary to her illness.
She normally receives HD DISEASE on Mon Wed and Fri.
3. Status post left femur fracture DISEASE
4. Hyponatremia DISEASE
5. Hypercholesterolemia DISEASE
6. Unsteady gait
7. Cataracts DISEASE
8. Back pain DISEASE
9. Hypertension DISEASE
10.Anemia of chronic disease DISEASE
11. S/P L shoulder hemiarthroplasty following a left humeral
fracuture in [**10/2159**]- [**Last Name (un) 4163**] was complicated by a PEA arrest DISEASE
secondary to PE.
12. PE [**2159-10-27**] leading to PEA arrest DISEASE

Social History:
Lives with son who is very involved and well informed regarding
her care needs. Non smoker. No EtOH


Family History:
Noncontributory

Physical Exam:
94.5 132/50 108 15 100%
AC 500/15/.50/PEEP 5
Gen- Sedated and intubated. Grimaces eyes when they are opened.
HEENT- NC AT. Right pupil ERRL. Surgical left pupil. Anicteric
sclera. MMM.
Cardiac- RRR. S1 S2. No mrg.
Pulm- CTA anteriorlly.
Abdomen- Obese. Soft. NT. ND. Positive bowel sounds.
Extremities- Feet mildly cool. 2Admission Date: [**2159-12-29**] Discharge Date: [**2160-1-6**]

Date of Birth: [**2090-1-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Losartan / Aspirin / Lisinopril-Hctz

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
fever hypotension DISEASE

Major Surgical or Invasive Procedure:
trans-esophageal echocardiogram


History of Present Illness:
69F with h/o ESRD DISEASE on HD PE (PEA arrest) recent admit for
sepsis DISEASE of unclear etiology from [**Date range (2) 4167**] presenting to
ED with fever DISEASE Tm 102 hypotension DISEASE decreased appetite and
lethargy DISEASE per son. Pt has had loose stools x 2 in the past few
days with hypomagnesemia DISEASE and hypophosphatemia DISEASE receiving PO
repletion w/o benefit. Pt received empiric Abx coverage of
Vanc/Cefepime/Levaquin/Flagyl at [**Hospital **] Rehab prior to transfer.
.
Recent hospitalization notable for intubation for airway
protection in setting of obtundation DISEASE no clear source of
infection DISEASE . Micro data remarkable for yeast and VRE DISEASE in urine for
which pt received 7d Fluconazole and 14d course of Linezolid (LD
[**2159-12-27**]). Pt intermittently on Flagly Cefepime until culture
data remained negative. Also failed [**Last Name (un) **] stim and was on stress
dosed steroids. No evidence of infection DISEASE in sputum blood or
CSF. CT Abd/Pel unremarkable. PICC removed and tunneled HD
catheter changed over wire on [**2159-12-18**] (from [**10-15**]). A new PICC
was inserted prior to discharge on [**12-18**].
.
In ED Tm 102 tachy 110-120 BP dropped to 82/17 intermittently
then improved to normal tachypneic 22-28 99% RA DISEASE . Received Gent
x 1 Fluconazole 400mg IV x1. ROS: denies any pain DISEASE or
localizable symptoms at this time. Per sons' report ptAdmission Date: [**2160-1-8**] Discharge Date: [**2160-1-16**]

Date of Birth: [**2090-1-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Losartan / Aspirin / Lisinopril-Hctz

Attending:[**First Name3 (LF) 4162**]
Chief Complaint:
fever hypotension DISEASE

Major Surgical or Invasive Procedure:
Hemodialysis MWF


History of Present Illness:
Pt is a 69 y/o female with ESRD DISEASE bed bound humeral and femoral
fracture DISEASE who was recently admitted to ICU with enterobacter/
klebsiella/Pseudomonas UTI DISEASE and bacteremia DISEASE on Gent Cefepime via
PICC who was admitted with increased change in mental status
less responsive and fever DISEASE x 1 day. Patient got HD DISEASE on [**2160-1-7**]
and when she came to the ED on [**1-8**] her SBP was found to be in
the 80s. Patient got 1.5L NS and BP returned to SBP 120s. Her
lactate was 1.0. ID DISEASE and renal consulted and ID DISEASE recommended
continuing patient on meropenum linezolid and Gentamycin.
Patient got vancomycin in ED.
.
History obtained from son on Transfer he states that pt was
discharged on saturday sunday she felt weak and was somnolent.
After dialysis on monday she became more lethargic and
unresponsive and was transferred to [**Hospital1 18**] ED. She got
Admission Date: [**2160-1-18**] Discharge Date: [**2160-3-5**]

Date of Birth: [**2090-1-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Losartan / Aspirin / Lisinopril-Hctz

Attending:[**First Name3 (LF) 4162**]
Chief Complaint:
aspiration hypoxia DISEASE


Major Surgical or Invasive Procedure:
Multiple intubations
Nasogastric tube
Left internal jugular central line
PEG tube placed and replaced


History of Present Illness:
This is a 69 year old bedbound Somalian speaking only woman well
known to [**Hospital1 18**] with end stage renal disease DISEASE on hemodialysis
diabetes mellitus DISEASE type 2 chronic hyponatremia DISEASE history of
pulmonary embolus DISEASE on coumadin and recent admissions to ICU with
enterobacter/klebsiella/pseudomonas bacteremia DISEASE who presents from
rehab with hypoxia DISEASE and decreased responsiveness in setting of
apparent aspiration. Events at rehab unclear but during
hemodialysis patient desatted to 74%. Apparently a code was
called but event details not known. Pt was suctioned which
produced Admission Date: [**2173-9-13**] Discharge Date: [**2173-9-17**]

Date of Birth: [**2103-10-30**] Sex: M

Service: OTOLARYNGOLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4181**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
1. Emergent cricothyrotomy with subsequent closure.
2. Tracheotomy with a #7 Portex tracheotomy tube.


History of Present Illness:
69-year-old patient with a history of T1 N0 squamous cell
carcinoma of the left true vocal cord DISEASE who presented to the ED
with respiratory distress DISEASE . Patient is currently under the care
of
Dr. [**First Name (STitle) 3311**] at [**Hospital1 112**] and has been treated with external beam
irradiation ending in [**Month (only) 216**]. Recently he has apparently been
treated for fungal mucusitis.

In the ED the patient was stridorous and was treated with
heliox. Accessory muscle use were required for breathing. With
treatment the patient significantly improved. After a
conversation with Drs. [**First Name (STitle) 3311**] and [**Name5 (PTitle) **] the decision was
made to go to OR for a tracheotomy to secure the airway.

The plan was to bring the patient to the OR for this reason.


Past Medical History:
1. Squamous cell carcinoma DISEASE as stated in history of present
illness.
2. Benign prostate hypertrophy DISEASE .
3. Diabetes mellitus DISEASE .
4. Gallbladder removal.
5. coronary artery disease DISEASE
6. perirectal abscess in [**2156**]
7. osteoarthritis DISEASE


Social History:
Mr. [**Known lastname 4182**] [**Last Name (Titles) 4183**] from [**Country 532**] in [**2155**]. He
worked as a construction engineer. He is married and lives with
his wife [**Street Address(1) 4184**]. They have one daughter who lives in
the area. The patient smoked one pack per day of unfiltered
cigarettes for 50 years.


Family History:
NC

Physical Exam:
Breathing well on heliox
No neck adenopathy DISEASE no neck masses
EOMI
Fiberoptic exam:
No supraglottic edema DISEASE left true cords minimally mobile
exudates
over cords c/w possible fungal infection DISEASE . Posterior glottic gap
4-5 mm.
Face symmetric


Pertinent Results:
[**2173-9-13**] 10:12PM CK-MB-7 cTropnT-Admission Date: [**2196-6-26**] Discharge Date: [**2196-7-4**]

Date of Birth: [**2137-10-7**] Sex: F

Service: [**Doctor Last Name 1181**]

HISTORY OF PRESENT ILLNESS: This is a 59-year-old woman
with multiple medical problems including coronary artery
disease status post coronary artery bypass graft chronic
obstructive pulmonary disease DISEASE on home oxygen
insulin-dependent diabetes mellitus DISEASE peripheral vascular
disease status post above the knee amputation bilateral
carotid endarterectomies femoral-popliteal bypass who
presented on [**6-26**] with shortness of breath DISEASE after being
found by her daughter obtunded and cyanotic DISEASE with the oxygen
nasal cannula removed. The patient presented to the
Emergency Room on [**6-26**] with shortness of breath DISEASE
progressive over the course of the preceding days. Her
daughter reported finding the patient cyanotic DISEASE and obtunded
lying in bed with her oxygen nasal cannula removed from her
face. The patient also reported progressively increasing
swelling DISEASE of her extremities in the days preceding admission.
On arrival to the Emergency Department the patient was 98%
on 3 liters nasal cannula. She denied any chest pain cough DISEASE
fever DISEASE or chills DISEASE .

According to the patient she had been admitted to [**Hospital 4199**]
Hospital several times between [**Month (only) 958**] and [**2196-4-22**] for
volume overload DISEASE and chronic obstructive pulmonary disease DISEASE
exacerbations. Per patient she was admitted in [**Month (only) 958**] for
three months and required three visits to the Medical
Intensive Care Unit with multiple intubations. She was
discharged from [**Last Name (un) 4199**] in [**Month (only) **] and she had just completed
her steroid taper that was initiated with these flares DISEASE . She
was then readmitted to [**Last Name (un) 4199**] on [**2196-6-10**] with nausea DISEASE
vomiting DISEASE and lethargy DISEASE and was found on admission to be
febrile DISEASE with a potassium of 6.8 a blood sugar of 460 and
elevated transaminases. At this time the hyperkalemia DISEASE was
thought secondary to Zestril which was discontinued. She
was treated with insulin and Kayexalate and discharged to
home on [**2196-6-22**].

PAST MEDICAL HISTORY:
1. Insulin-dependent diabetes mellitus DISEASE
2. Chronic obstructive pulmonary disease DISEASE (dependent on home
oxygen uses steroids during flares DISEASE history of multiple
intubations)
3. Coronary artery disease DISEASE status post coronary artery
bypass graft in [**2189**]
4. Peripheral vascular disease DISEASE status post femoral-popliteal
bypass right above the knee amputation bilateral carotid
endarterectomies
5. Status post abdominal aortic aneurysm DISEASE repair
6. Bipolar disorder DISEASE

ALLERGIES: Sulfa Tolinase

SOCIAL HISTORY: The patient lives alone in [**Hospital3 **].
Her daughter lives in the area and helps to care for her.
Her daughter has offered to have the patient move in with
her but the patient has been reluctant to do so for fear of
becoming a burden to her daughter. The patient admits to
multiple suicide attempts with pills in the last few years
most recently a few months ago. The patient also reports
severe depression DISEASE following the death DISEASE of her husband from
[**Name (NI) 2481**] disease last year. The patient also expresses
extreme frustration with the intensive medical care which she
has had to receive over the course of the last few years.

PHYSICAL EXAMINATION: On admission to the Emergency
Department the patient had a temperature of 97.7 pulse of
70 blood pressure 105/54 respiratory rate 14 and oxygen
saturation of 98% on 3 liters by nasal cannula. In general
she was comfortable breathing rapidly in no acute distress.
Head eyes ears nose and throat examination showed the
patient to have severe facial edema DISEASE and her extraocular
muscles were intact pupils equal round and reactive to
light. On neck examination there was no jugular venous
distention and no carotid bruits DISEASE . On lung examination she
had decreased air movement in both lung fields but no
wheezes or rales DISEASE . On heart examination she had distant
heart sounds a regular rate and rhythm with a II/VI systolic murmur DISEASE loudest at the right upper sternal border
with no gallops. On abdominal examination she had normal
active bowel sounds DISEASE . Her abdomen was soft nondistended and
nontender. There was no hepatosplenomegaly DISEASE and no guarding
or rebound. On extremity examination her right leg (status
post above the knee amputation) there was pitting edema DISEASE in
the thigh. In her left leg there was pitting edema DISEASE to the
thigh. On neurological examination she was alert and
oriented x 3 extraocular muscles were intact pupils equal
round and reactive to light moved three extremities 2Admission Date: [**2203-10-4**] Discharge Date: [**2203-10-26**]

Date of Birth: [**2143-10-4**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
Codeine / Streptokinase / Iodine / Bee Pollens / Narcan

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Admission Date: [**2203-11-19**] Discharge Date: [**2203-12-16**]

Date of Birth: [**2143-10-4**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
Codeine / Streptokinase / Iodine / Bee Pollens / Narcan

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Altered mental status


Major Surgical or Invasive Procedure:
VP shunt removal [**2203-11-20**]
VP shunt placement [**12-6**]
removal of Kwires R arm [**11-22**]


History of Present Illness:
Mr. [**Known lastname 3989**] is a 60y/o gentleman with HTN DISEASE HLD CAD s/p MI AFib DISEASE
TIA colon cancer DISEASE s/p resection s/p abdominal trauma DISEASE with
splenectomy and left hand digit amputations right forearm
fracture DISEASE with plan for hardware removal [**11-22**] as well as
complicated hospital course last month for spontaneous SAH DISEASE and
pneumonia DISEASE now s/p trach/PEG/VP shunt who was sent from rehab to
an OSH for altered mental status and was transferred to [**Hospital1 18**]
due to concern for VP shunt complication vs infection DISEASE .

He was admitted to Neurosurgery [**Date range (1) 4216**] after presenting to an
OSH with the Admission Date: [**2161-9-22**] Discharge Date: [**2161-10-1**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Hypothermia DISEASE at Dilaysis

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 84 y.o. female with h/o ESRD DISEASE on HD DISEASE recent
admission for C diff colitis DISEASE in [**2161-8-6**] a resident at
[**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **] admitted [**2161-9-22**] after she was found to be
hypothermic during HD yesterday. The patient with recent stool
positive for cdiff at nursing home (C.Diff Admission Date: [**2172-3-5**] Discharge Date: [**2172-3-8**]

Date of Birth: [**2109-10-8**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Meningioma DISEASE

Major Surgical or Invasive Procedure:
Right Craniotomy


History of Present Illness:
[**Known firstname 622**] [**Known lastname 1836**] is a 62-year-old woman with longstanding
history of rheumatoid arthritis DISEASE probable Sweet's syndrome DISEASE and
multiple joint complications requiring orthopedic interventions.
She was found to hve a right cavernous sinus and nasopharyngeal
mass. She underwent a biopsy of hte nasopharyngeal mass by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] and the pathology including flow
cytometry
was reactive for T-cell lymphoid hyperplasia DISEASE only.

She has a longstanding history of rheumatoid arthritis DISEASE that
involved small and large joints in her body. Her disease is
currently controlled by abatacept hydroxychloroquine and
methotrexate. She also has a remote history of erythematous
nodules at her shins dermatosis (probable Sweet's disease DISEASE )
severe holocranial headache DISEASE with an intensity of [**9-28**] and
dysphagia. But her symptoms resolved with treatment for
autoimmune disease DISEASE . Please refer additional past medical
history past surgical history facial history and social
history to the initial note on [**2171-11-4**].

She cam to the BTC for discussion about management of her right
cavernous sinus mass that extends into the middle cranial fossa.


She had a recent head CT at the [**Hospital1 756**] and Woman's Hospital on
[**2171-11-29**] when she went for a consultation there.
She is neurologically stable without headache nausea vomiting DISEASE
seizure DISEASE imbalance or fall. She has no new systemic complaints.

Her neurological problem started [**9-/2171**] when she experienced
frontal pressure-like sensations. There was no temporal
patternAdmission Date: [**2136-4-4**] Discharge Date: [**2136-4-9**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fatigue DISEASE

Major Surgical or Invasive Procedure:
R IJ placement

History of Present Illness:
This is a 84 year-old Russian speaking female with a history of
systemic hypertension DISEASE pulmonary arterial hypertension DISEASE chronic
diastolic CHF DISEASE who presents with hypotension DISEASE drop in hematocrit
and guaiac positive stools. She reportedly collapsed 3 times
today. Per son patient felt lightheaded every time she stood
up and had to sit back down to the floor. She has never had a
problem like this in the past. Denies any NSAID or alcohol use.
Denies hematemesis DISEASE . Occasional blood-tinged stool when she
strains but denies hematochezia DISEASE . Denies any fevers DISEASE . Denies
black or bloody stools but stool always black because of iron.
Of note patient was recently admitted and discharged on
[**2136-4-2**] with multifocal pneumonia DISEASE .

In the ED initial vitals were T:98.3 BP:81/20 HR:79 O2 Sat
100% on 4L. NG lavage was negative. Patient received 2 units
PRBC and right IJ placed for persistent hypotension DISEASE .
.
ROS: The patient denies any fevers chills DISEASE weight change
nausea vomiting diarrhea constipation chest pain orthopnea DISEASE
PND lower extremity oedema cough urinary frequency urgency
dysuria lightheadedness gait unsteadiness focal weakness DISEASE
vision changes headache rash DISEASE or skin changes.


Past Medical History:
#. Pulmonary HTN DISEASE on 2 litres home O2
#. CHF DISEASE - last echo [**8-1**]: ef Admission Date: [**2161-11-21**] Discharge Date: [**2161-12-16**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Tracheostomy
Central Line Placement


History of Present Illness:
This is a 84 y/o with h/o ESRD DISEASE A fib who comes to the
Emergency Department after being found on HD with increasing
shortness of breath DISEASE . Patient found to be 10L positive but they
were unable to take enough fluid off so they took off 2L.
Patient describes that over the last few weeks she has been
feeling a little more short of breath. She reports one Admission Date: [**2190-3-27**] Discharge Date: [**2190-3-28**]

Date of Birth: [**2157-12-22**] Sex: F

Service: NEUROLOGY

Allergies DISEASE :
Penicillins / Aspirin

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
syncopal DISEASE episode

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Known firstname 4252**] is a 32 year old right handed woman with a history
of hypertension DISEASE (post partum only) migraine headaches DISEASE and G6PD DISEASE
deficiency who presents to the [**Hospital1 18**] ED as a transfer from the
[**Hospital Ward Name **] where she was noted to have a syncopal DISEASE episode when
waiting to get a scheduled lumbar spine MRI due to complaints of
lower back pain DISEASE localized to the region of her epidural (present
only since pregnancy).

She is somnolent at the time of this history but states that
she
was given a prescription for some medicine to be taken prior to
the procedure. She took 4 pills and refers to a bottle of
lorazepam 1mg tablets. Witnesses (per ED staff) state that she
lost consciousness but did not have any evidence of seizure DISEASE
activity. Her vital signs at that time were notable for a blood
pressure of 180/110. She was noted to be oriented but lethargic
and was sent to the ED for further evaluation.

Upon arrival to the ED she had a CT of her head that was
negative for any abnormality. The patient herself states that
she
was on pain DISEASE medication (tylenol #3 and percocet for her back
pain DISEASE but discontinued this due to the fact that the medication
was making both her and her baby constipateAdmission Date: [**2103-3-5**] Discharge Date: [**2103-3-11**]


Service: MEDICINE

Allergies DISEASE :
Augmentin

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Mixed respiratory failure DISEASE

Major Surgical or Invasive Procedure:
Intubation
CVL

History of Present Illness:
Mrs. [**Known lastname **] is an 87 year old female with a PMH significant
for HTN asthma DISEASE and chronic mixed respiratory failure DISEASE followed
by Dr. [**Last Name (STitle) **] now admitted for hypoxemic respiratory failure DISEASE . The
patient was found by her family this morning in her bedroom
confused after possibly falling. At that time she was
disoriented and looked short of breath with a Admission Date: [**2144-12-2**] Discharge Date: [**2144-12-16**]

Date of Birth: [**2103-3-23**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Sulfonamides

Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Found unresponsive by friends.

Major Surgical or Invasive Procedure:
Endotracheal intubation
Ventriculostomy
Lumbar punctures

History of Present Illness:
41 year-old female with a PMHx significant for major depression DISEASE
and migraine headaches DISEASE transferred from Mt. [**Hospital 4257**] Hospital
where she was brought after being found unresponsive by her
friends.

Per report Ms. [**Known lastname 4258**] was diagnosed with otitis DISEASE media in the
week prior to admission and treated with Z-pac and cortisporin
ear drops. 2 days PTA she complained of a severe headache DISEASE
Admission Date: [**2155-10-28**] Discharge Date: [**2155-11-11**]

Date of Birth: [**2098-5-26**] Sex: M

Service: [**Hospital1 **]

CHIEF COMPLAINT: Change in mental status.

HISTORY OF PRESENT ILLNESS: This is a 57-year-old gentleman
with a complicated past medical history including end-stage
renal disease DISEASE on hemodialysis insulin-dependent diabetes DISEASE
mellitus DISEASE chronic MRSA infection DISEASE of an aorto-aortic graft
aortic dissection status post repair in [**2143**] coronary artery
disease status post coronary artery bypass grafting who
presented with a three-week history of increased confusion DISEASE
and somnolence DISEASE .

According to the patient's family the patient had a slowly
declining mental status over the past three monthsAdmission Date: [**2166-12-29**] Discharge Date: [**2167-1-2**]

Date of Birth: [**2096-10-9**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4272**]
Chief Complaint:
70 y/o female w/ asymptomatic LUL nodule found on routine PE
CXRAY by PCP. [**Name10 (NameIs) 4273**] constitutional symptoms.

Major Surgical or Invasive Procedure:
LUL lobectomy for LUL nodule


History of Present Illness:
70 y/o female w/ asymptomatic LUL nodule found on routine PE
CXRAY by PCP [**Name10 (NameIs) **] Constitutional symptoms.

Past Medical History:
HTN DISEASE MR RA DISEASE Lumbar fusion [**2161**]
TTE: LVEF Admission Date: [**2169-12-5**] Discharge Date: [**2169-12-5**]

Date of Birth: [**2096-10-9**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Cardiac catheterization

History of Present Illness:
73 y/o M with h/o lung CA renal CA s/p right proximeral
femoral resection and reconstruction with tumor DISEASE prosthesis
[**11-14**] recently d/c from [**Hospital1 18**] [**2169-11-22**] to rehab.
.
Patient was refered to the Ed after VNA call physician with
hypotension DISEASE [**Name9 (PRE) 4280**] and low PO intake. On arrival patient
with respiratory distress tachypneic DISEASE tachycardic. VS Hr 154
Bp 189/88 RR 28 Sats 100%. EKG stE v2-v4 st depression DISEASE v5 v6
I and AVL DISEASE . She was also tachycardic and adenosin Admission Date: [**2134-12-3**] Discharge Date: [**2134-12-7**]

Date of Birth: [**2063-8-6**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Chief Complaint: fever DISEASE

Reason for MICU transfer: hypotension DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
A 71 year old male with PMH Cholelithiasis DISEASE and biliary colic DISEASE s/p
unsuccessful open cholecystectomy is called out of the MICU
after a one day hospitalization for hypotension DISEASE following ERCP.
.
According to the patient he had an episode of abdominal pain DISEASE in
[**9-/2134**] and presented to [**Hospital6 4287**] where he underwent an
attempted laparoscopic cholecystectomy which was converted to an
open proceedure DISEASE due to fibrosis DISEASE . He reports that the surgeon was
able to remove some stones and closed leaving a bile drain in
place. He was then sent to [**Hospital1 18**] for ERCP on [**2134-10-28**] with
biliary stent placement which was successful. Following the
procedure the patient noted decreased output from the external
biliary drain and had resolution of abdominal pain DISEASE . On the day
of admission ([**2134-12-2**]) the patient presented for an repeat ERCP
to place a larger biliary stent which was performed
successfully. He returned home where he noted chills DISEASE and an oral
temperature of 100.7. He called his PCP who recommended referral
to the ED. In the ED initial VS were: 98.3 78 91/52 18 94%
Labs were remarkable for WBC 5.0 73%PMN 3% Bands he was given
amp/sulbactam and 2L IVNS and admitted to the MICU.
.
While in the MICU antibiotics were changed to vancomycin and
zosyn. Biliary drain fluid was cultured with initial gram stain
showing Gram Neg Rods and Gram positive Cocci DISEASE and culture
showing polymicrobial growth. ERCP fellow was [**Month/Day/Year 653**] who
noted that the fluid in a cholecystomy bag is rarely cultured
and is likely to be colonized with non-pathogenic bacteria. The
patient was given a total of 5 liters of fluid in the ED and
MICU. BP has now been stable without requring fluid for over 24
hrs and therefore patient was able to leave the MICU.
.
On arrival to the floor patient denies any current complaints
and states that he feels as well as he normally does at home.
.
REVIEW OF SYSTEMS
On review of systems he denies any prior history of stroke DISEASE
TIA DISEASE deep venous thrombosis pulmonary embolism bleeding DISEASE at the
time of surgery myalgias DISEASE joint pains cough hemoptysis DISEASE black
stools or red stools. He denies exertional buttock DISEASE or calf pain DISEASE .
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain DISEASE
dyspnea DISEASE on exertion paroxysmal nocturnal dyspnea orthopnea DISEASE
ankle edema palpitations syncope DISEASE or presyncope DISEASE .

Past Medical History:
HTN DISEASE
hyperlipidemia DISEASE
Type II DM DISEASE
Status post carotid endarterectomy
Thrombocytopenia DISEASE
Fibrotic lung disease DISEASE : Likely due to asbestosis DISEASE
Bladder CA status post TURBT


Social History:
Lives in [**Location 4288**] with his wife and son. Significant 30Admission Date: [**2132-7-9**] Discharge Date:

Date of Birth: [**2098-11-23**] Sex: M

Service: Orthopaedic Surgery

HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 4297**] is a 33-year-old
male who was a restrained passenger in a 110 mile per hour
motor vehicle versus tree collision in [**Hospital3 4298**] on
[**2132-7-8**]. The driver in the same vehicle was dead on
arrival.

The patient was transferred by med-flight from [**Hospital6 4299**] to the [**Hospital1 188**]. By report he was awake and alert at the outside
hospital. He was then sedated and intubated. He was noted
to be tachycardic and hypotensive DISEASE on arrival at [**Hospital1 346**]. Evidence of multiple fractures DISEASE and
dislocations DISEASE .

He was admitted to [**Hospital1 69**] on
[**2132-7-9**]Admission Date: [**2199-7-13**] Discharge Date: [**2199-7-16**]

Date of Birth: [**2116-9-4**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
82F h/o prior CVA with residual R-sided weakness AS ([**Location (un) 109**] 1.2
cm2) cecal and splenic flexure masses admitted with chest pain DISEASE .
Describes 3 days of chest pain DISEASE that radiates across the chest
occuring only while supine at night describes as a constant
Admission Date: [**2139-11-24**] Discharge Date: [**2139-12-4**]


Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
somnolence DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is an 87 year old lady with a PMH of diastolic heart
failure (EFAdmission Date: [**2199-7-28**] Discharge Date: [**2199-8-5**]

Date of Birth: [**2116-9-4**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Chest pain DISEASE and bright red blood per rectum

Major Surgical or Invasive Procedure:
Colonoscopy [**2199-8-2**]
Bleeding scan [**2199-7-30**]
Transfused 6 units PRBC


History of Present Illness:
82 yo F with hx of prior CVA with residual R-sided weakness AS
([**Location (un) 109**] 1.2 cm2) known cecal and splenic flexure masses recently
admitted for sub-sternal chest pressure in the setting of BRBPR
and a Hct of 20.8 presents with substernal chest pressure in
setting of BRBPR.
.
Of note the patient was admitted from [**2199-7-13**] through [**2199-7-16**]
with BRBPR acute on chronic anemia DISEASE and chest pain DISEASE with ECG
changes. The patient was observed in the MICU for 1 day and
given a total of 4pRBCs on [**2199-7-13**] that brought her Hct from
20.8 to 30.8. The patients chest pain DISEASE subsequently resolved and
she was discharged home. There was a recommendation for tagged
RBC scan during that admission however she had no further
episodes of bleeding DISEASE during the hospitalization.
.
Since discharge the patient has had mulitple episodes of BRBPR.
Last night the pt noted Admission Date: [**2186-12-11**] Discharge Date: [**2186-12-13**]

Date of Birth: [**2136-6-19**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
CHEST PAIN

Major Surgical or Invasive Procedure:
Catheterization

History of Present Illness:
Mr. [**Known lastname 4318**] is a 50 yo M with history of prior anterior MI s/p
DES to LAD DISEASE in [**8-29**] who presented to ED after experiencing CP
since 9am and found to have inferior STE. He was working on his
truck this am when he started to have chest tightness DISEASE and
diaphoresis DISEASE that felt similar to his prior heart attack. He
rated it as a [**8-4**]. The night prior he said he took an antacid
for what he thought was gas pain DISEASE . He says he had not taken any
of his medications in 6 months except his aspirin. He had
co-workers call 911.
.
In the ED initial vitals were 78 118/87 16 100%NRB. Given
nitro morphine plavix 600mg and started on integrillin.

He was taken to cath where he has near occlusion of OM and
underwent export thrombectomy followed by direct stenting with a
3.0x15mm Endeavor DISEASE post-dilated to 3.25mm. An LVgram showed EF
in 40% marked LV dysfunction DISEASE 40% (anterior apical and
posterolateral HK). LVEDP Admission Date: [**2189-1-15**] Discharge Date: [**2189-1-17**]

Date of Birth: [**2136-6-19**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
STEMI

Major Surgical or Invasive Procedure:
[**2189-1-15**] - Left heart cardiac catheterization with bare metal
stent placed in the LAD


History of Present Illness:
52 year old male with coronary artery disease DISEASE s/p MI DISEASE s/p PCI to
LAD and LCx ([**2181**] [**2186**]) and s/p right atrial tachycardia DISEASE
ablation [**6-/2188**] with decreased ejection fraction (EF 20% from
40% in [**2186**]) presenting with chest pain DISEASE found to have STEMI
enroute by EMS. Patient woke up 3:30 am this morning at home
and reports tightness across his chest not localizing anywhere
specific. Patient reports the chest pain DISEASE is similar to his past
MI 4 years ago when he got stents placed in the LAD. He took
325 aspirin PO before he got here. he is clammy DISEASE . pain DISEASE was [**5-4**]
initially. After nitro the pain DISEASE was [**2-4**]. He was taking
lisinopril metaprolol. Stopped taking those meds because he ran
out refills no other reason.
.
In ED he was 80 BP 138/100 Resp 20 O2 Sat 100%. EKG noted STE
in V1-V4 with Qs in II III AVF. Exam was notable for
diaphoresis DISEASE and chest tightness DISEASE 40 min prior to presentation.
Labs were notable for trop of 0.01 otherwise benign. He was
given plavix heparin gtt taken to the cath [**Month/Year (2) **] for urgent
intervention. He was found to have LAD in stent thrombosis DISEASE
used 160cc of dye was given bival DISEASE in labs. BMS x 1 to LAD RFA
access. Angiosealed.
.
In CCU patient appeared to be in good spirit.
.
On review of systems s/he denies any prior history of stroke DISEASE
TIA DISEASE deep venous thrombosis pulmonary embolism bleeding DISEASE at the
time of surgery myalgias DISEASE joint pains cough hemoptysis DISEASE black
stools or red stools. S/he denies recent fevers chills DISEASE or
rigors. S/he denies exertional buttock DISEASE or calf pain DISEASE . All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain DISEASE
dyspnea DISEASE on exertion paroxysmal nocturnal dyspnea orthopnea DISEASE
ankle edema palpitations syncope DISEASE or presyncope DISEASE .
.


Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes Admission Date: [**2136-6-10**] Discharge Date: [**2136-7-11**]

Date of Birth: [**2093-2-11**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Thorazine / Haldol / Risperdal / Codeine / Demerol / Darvon

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
CC:[**CC Contact Info 4329**]
Major Surgical or Invasive Procedure:
L. 1st MPJ arthrocentesis [**2136-6-20**]
I&D Left Lower Extremity [**2136-6-13**]
PICC LINE placement. [**2136-6-25**]
L 1st joint arthrocentesis [**2136-7-5**]


History of Present Illness:
HPI: 43 yo M with h/o schizophrenia DISEASE and self-abusive behavior
resulting in recurrent cellulitis DISEASE and [**Hospital 4330**] transferred to [**Hospital1 18**]
for Admission Date: [**2132-7-9**] Discharge Date: [**2132-10-1**]

Date of Birth: [**2098-11-23**] Sex: M

Service:

ADMISSION DIAGNOSIS:
IM roding of right femur open reduction and internal
fixation of right femoral head rod left talus right
caliectomy Admission Date: [**2185-11-22**] Discharge Date: [**2185-11-29**]


Service:

HISTORY OF PRESENT ILLNESS: This is an 80-year-old gentleman
with a recent history of exertional DISEASE chest discomfort
positive stress test was obtained and he was referred to
[**Hospital1 69**] for cardiac
catheterization.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE .
2. Osteoarthritis DISEASE .
3. Benign prostatic hypertrophy DISEASE .
4. Chronic back pain DISEASE secondary to spinal stenosis.
5. Lumbar radiculopathy DISEASE .
6. Known coronary artery disease DISEASE with EKG evidence of prior
myocardial infarction DISEASE .
7. Status post right rotator cuff repair.
8. History of upper GI bleed.
9. Gastric ulcer DISEASE .
10. Vertigo DISEASE .

MEDICATIONS UPON ADMISSION TO HOSPITAL:
1. AndroGel 1% q.d.
2. Atenolol 50 mg q.d.
3. Lipitor 40 mg q.d.
4. Colace 100 mg t.i.d.
5. Lisinopril unknown dose.
6. Neurontin 300 mg q.h.s.
7. Nitroglycerin 0.4 mg sublingual prn.
8. Norvasc 10 mg p.o. q.d.
9. Nitro patch 0.2 q.d.
10. Protonix 40 mg q.d.
11. Quinine 260 mg h.s.
12. Tylenol with codeine #3 prn.
13. Ultram q.i.d. prn.
14. Vioxx 12.5 b.i.d. prn.

ALLERGIES: The patient states no known drug allergies DISEASE .

Echocardiogram obtained in [**2185-3-8**] revealed left
ventricular ejection fraction 60% dilated ascending aorta
and mild aortic stenosis DISEASE and mild mitral annular
calcification DISEASE .

Catheterization obtained revealed LVEDP of 17 90% left main
stenosis 80% proximal right coronary artery stenosis DISEASE . Due
to the anatomy of the patient's lesions an intra-aortic
balloon pump was inserted in the Cardiac Catheterization
Laboratory and he was taken to the Coronary Care Unit
preoperatively.

Laboratory values upon admission to the hospital were
unremarkable with the exception of a creatinine of 1.2.

PHYSICAL EXAMINATION UPON ADMISSION TO THE HOSPITAL: Was
also unremarkable.

Patient was taken to the operating room on [**2185-11-23**]
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] cardiothoracic surgeon. Patient
underwent coronary artery bypass graft x3 with a LIMA to the
LAD saphenous vein to the right coronary and a saphenous
vein to the obtuse marginal. Postoperatively he was
transported in good condition from the operating room to the
Cardiac Surgery Recovery Unit.

The night of surgery the patient was weaned from mechanical
ventilation and extubated successfully. On postoperative day
one he was off vasoactive drips. He was hemodynamically
stable. His intra-aortic balloon pump was discontinued. He
was begun on Lasix as well as a beta blocker.

Later in the day on postoperative day one the patient was
transferred from the Intensive Care Unit to the telemetry
floor in good condition.

In postoperative day two the patient remained
hemodynamically stable. He was transfused 1 unit of packed
red blood cells for a hematocrit of 23. He was begun with
Physical Therapy and cardiac rehabilitation. He continued on
Lopressor and Lasix. Patient continued to progress over the
next couple of days with cardiac rehabilitation increasing
mobility and ambulating with less assistance. Patient did
receive a total of 3 units of packed red blood cells on
postoperative day two to postoperative day three for a drop
in hematocrit.

On postoperative day four patient continued to work with
aggressive physical therapy. He was still not completely
independent at that time but was progressing in satisfactory
condition. Today on postoperative day six the patient
remained hemodynamically stable and ready to be discharged
to home.

Patient's condition today is as follows: He is afebrile.
His weight is 68.4 kg today which is just about his
preoperative weight of 68 kg. His wounds are clean dry and
intact. His lungs are clear to auscultation bilaterally.
His abdomen is soft nondistended and nontender. He has 1Admission Date: [**2160-10-12**] Discharge Date: [**2160-10-15**]

Date of Birth: [**2101-11-10**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
difficulty walking abdominal fullness DISEASE

Major Surgical or Invasive Procedure:
Placement of femoral central line with subsequent removal
One episode of hemodialysis
foley catheter placement


History of Present Illness:
This is a 58yoM with history of DM HTN HLD obesity DISEASE who
presents from urgent care clinic with grossly abnormal labs.
.
Patient was in USOH until beginning of [**Month (only) 359**] when he developed
lower back pain DISEASE . After seeing his PCP [**Name10 (NameIs) **] was started on
Tylenol#3 and flexeril. He then represented on [**10-3**] for severe
constipation DISEASE x 3 days. He was started on MOM with good results.
At this appt he also complained of dysuria DISEASE for which urine
culture was obtained and was negative. He represented again on
[**10-11**] for severe constipation DISEASE . Plan was to try OTC drugs and
follow up on [**10-12**]. Per office note patient appeared weak and
had protuberant abdomen. KUB from office note showed evidence of
Admission Date: [**2143-1-29**] Discharge Date: [**2143-2-4**]

Date of Birth: [**2074-5-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname 174**] is a 68 year-old man with IgA meyloma DISEASE s/p Velcade
(last treatment [**2143-1-4**]) DM2 CKD DISEASE and schizophrenia DISEASE who
presents from his [**Hospital3 **] with confusion DISEASE and is admitted
to the MICU for sepsis/hypotension.
.
He was in his USOH until three days ago when nursing staff
noticed that he was more confused. Today he was noted by staff
to have high finger sticks (glucose Admission Date: [**2147-9-8**] Discharge Date:


Service:

ADDENDUM: Remove Captopril from the discharge medication list
and add Prinivil 40 mg by mouth every day. For the medication
Diflucan change the strength from 400 mg to 100 mg by mouth
every day times two more days.

Add to follow-up instructions the patient is to follow-up
with Dr. [**Last Name (STitle) **] as an outpatient and she is to follow-up
with the [**Hospital1 69**] [**Hospital 2663**]
Clinic for an endometrial biopsy. This clinic can be reached
at area code [**Telephone/Fax (1) 2664**].






Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36

D: [**2147-9-20**] 13:06
T: [**2147-9-20**] 14:48
JOB#: [**Job Number 2666**]
Admission Date: [**2147-9-8**] Discharge Date: [**2147-9-20**]



HISTORY OF PRESENT ILLNESS: The patient is an 88 year old
female with coronary artery disease congestive heart failure DISEASE
and diabetes mellitus DISEASE who presented with fever DISEASE abdominal
pain DISEASE after being found down at her nursing home. Her history
patient is a resident at [**Hospital3 2558**] who was found status
post questionable fall the morning of admission and was noted
to have a left-sided weakness without head trauma DISEASE or loss of
consciousness. The fall was unwitnessed. Subsequently the
patient had a large occult blood positive stool and was also
found to have complaints of abdominal pain DISEASE . At the nursing
home the temperature was 102.1 with a pulse of 126 blood
in by ambulance to [**Hospital6 256**]
Emergency Department for evaluation with a temperature of
103.2 pulse 120 blood pressure 108/40 and respiratory rate
of 30 with an oxygen saturation of 94%. In the Emergency
Department the patient was found to have an increased
respiratory rate. She denied cough chest pain shortness DISEASE of
breath nausea DISEASE and vomiting DISEASE or dysuria DISEASE . She did complain of
abdominal pain DISEASE and diarrhea DISEASE . The patient is demented at
baseline. The patient denied any fevers DISEASE or chills DISEASE prior
though it is unclear but it is possibly p.o. intake had been
decreased for several days.

PAST MEDICAL HISTORY: Coronary artery disease DISEASE status post
congestive heart failure DISEASE with last admission in [**2144-4-5**]
for diastolic heart failure Type 2 diabetes dementia DISEASE
benign positional vertigo DISEASE status post cholecystectomy
status post femoral neck fracture DISEASE on the right with a
hemiarthroplasty chronic anemia DISEASE with hematocrit of 29 and
B12 deficiency DISEASE .

ALLERGIES: Benzodiazepine which causes severe agitation DISEASE .

ADMISSION MEDICATIONS:
1. Multivitamin
2. Enteric coated Aspirin 325 mg p.o. q.d.
3. Lasix 40 mg p.o. q.d.
4. Prinivil 30 mg p.o. q.d.
5. Megace 400 mg p.o. b.i.d.
6. Lopressor 25 mg p.o. b.i.d.
7. Isordil 30 mg p.o. t.i.d.
8. Neurontin 100 mg p.o. q. 6
9. Colace 100 mg p.o. b.i.d.

PHYSICAL EXAMINATION: Physical examination revealed a
temperature of 103.2 pulse 120 blood pressure 108/40 and
respiratory rate of 30 and oxygen saturation of 94%. The
patient was an awake alert tachypneic elderly white female
in mild distress. Pupils were left surgical minimally
reactive right reactive. Extraocular muscles grossly
intact. Oropharynx mucous membranes were dry edentulous.
Neck was supple with jugulovenous distension of 10 cm no
lymphadenopathy DISEASE . Cardiovascular examination tachycardiac
normal S1 and S2. Lungs with decreased breath sounds DISEASE
bilaterally anteriorly at the bases otherwise clear to
auscultation. Abdomen was diffusely tender with bowel
sounds no masses no organomegaly DISEASE and mild distention.
Occult blood positive brown stool per the Emergency
Department. Back examination positive costovertebral angle
tenderness DISEASE bilaterally per Emergency Department. Extremities
with 1Admission Date: [**2139-12-25**] Discharge Date: [**2139-12-31**]


Service: ORTHOPAEDICS

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
Right subtrochanteric femur fracture DISEASE

Major Surgical or Invasive Procedure:
[**2139-12-26**] - Trochanteric femoral nail for right subtrochanteric
femur fracture DISEASE


History of Present Illness:
87F s/p fall this AM transferred here from [**Hospital3 2005**]
for R subtrochanteric femoral fx. She states she currently
doesn't have any pain DISEASE . She does not know how she fell. She was
found by her aid at home on the floor by her bed. She denies HA
CP neck pain. She was recently admitted to the MICU for CHF DISEASE
exacerbation from [**2139-11-24**] to [**2139-12-4**]


Past Medical History:
1. Falls multiple noted in OMR & D/C summaries
2. Pulmonary HTN DISEASE on 2L/nc Admission Date: [**2138-11-8**] Discharge Date: [**2138-11-9**]

Date of Birth: [**2055-4-30**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Vicodin

Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Thirst

Major Surgical or Invasive Procedure:
None

History of Present Illness:
83 year old woman with PMR on prednisone recently on
azathioprine IDDM CKD Stage 3 and h/o colon CA s/p resection
[**2122**] presenting with thirst hypovolemia hyperglycemia DISEASE and
hyperkalemia DISEASE . Patient reports persistent diarrhea DISEASE [**5-22**] loose
watery dark black-green stools DISEASE per day x last week attributed to
azathioprine which was subsequently discontinued 2 days PTA. Had
trace blood on tissue but no hematochezia DISEASE . She took immodium
yesterday and had some mild improvement in her symptoms but
diarrhea DISEASE has persisted today. She had mild crampy lower
abdominal pain DISEASE and chest pressure several days ago now both
resolved. CP was associated with indigestion and improved with
maalox. Overall she has been feeling unwell for last week but
denies fever DISEASE or chills DISEASE and reports good PO intake. She was
recently restarted on prednisone approx. 1 month ago and has
noted overall weight gains [**Last Name (un) 2675**] that time but no change in LE
edema DISEASE . Also reports SOB for months which is stable. Denies DISEASE
cough dysuria DISEASE current abd pain DISEASE CP N/V. Finger sticks athoem
have been high 200s.
.
In the ED initial vs were: 98.0 112 145/57 20 99%RA. Initial
labs significant for [**Last Name (un) **] with Cr 1.8 from 1.6 glucose 500s K
8.8 7.9 on repeat Na 122. In the ED she received 2LNS 1 amp
bicarb 30 kayexalate 20 units IV insulin and glucose improved
to 170s and K improved to 5.3. ECG revealed sinus tach no
peaked Ts or other signs of hyperkalemia DISEASE . Had CT abdomen which
was overall negative for acute process. Has had persistently
high lactate 2.7-2.8. Now being admitted to MICU with
tachycardia DISEASE and elevated lactate. VS prior to trasnfer: 97.8
119/57 119 20 99%RA 100%2L.
.
On the floor she complains mostly of thirst DISEASE and dry mouth DISEASE and
otherwise denies other complaints as above.
.
Review of systems:
(Admission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**]

Date of Birth: [**2095-1-13**] Sex: M

Service: COLORECTAL SURGERY SERVICE

HISTORY OF PRESENT ILLNESS: This is a 74 year old gentleman
with a history of prostate cancer DISEASE who presented in [**Month (only) 1096**]
of last year with rectal bleeding DISEASE . Evaluation included a
colonoscopy which showed an ulcerative lesion DISEASE in the rectum.
These were biopsied and showed moderately differentiated
adenocarcinoma DISEASE . The patient presents for curative resection.

PAST MEDICAL HISTORY: Prostate cancer DISEASE with radiation
implants and external beam radiationAdmission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**]

Date of Birth: [**2095-1-13**] Sex: M

Service:

ADDENDUM: This is a continuation of the previously dictated
discharge summary dated [**2169-2-27**] an update of the patient's
condition.

Mr. [**Known lastname 2684**] was initially started on Imodium for high
ileostomy outputs totaling 2-3 liters per day. This had been
coming down at the time of beginning the Imodium to about 2Admission Date: [**2169-5-6**] Discharge Date: [**2169-5-9**]

Date of Birth: [**2095-1-13**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
gentleman with a history of rectal adenocarcinoma DISEASE and is
status post proctosigmoidectomy with coloanal anastomosis and
loop ileostomy with multiple admissions for partial
small-bowel obstructions who now presents with
lightheadedness DISEASE and vomiting DISEASE .

The patient was last discharged from this hospital on [**2169-4-28**] after a 1-week admission for a partial small-bowel
obstruction. This was his third documented episode of a
partial small-bowel obstruction DISEASE since his surgery in [**2168-12-28**]. The patient reports that he was doing well at the
time of discharge with good oral intake. Moreover over that
period time he had been told by both his urologist and his
primary care physician to drink plenty of water to help with
his prostatic hypertrophy DISEASE .

Then over the next two to three days prior to admission the
patient reported a few episodes of lightheadedness feeling
that he might feel faint. He denied any accompanying chest
pain DISEASE shortness of breath or palpitations. This occurred
when he was standing and ambulating and resolved with rest.
Subsequently this afternoon he reports the onset of nausea DISEASE
with clear emesis DISEASE times one (there were no coffee grounds or
frank blood in the emesis DISEASE ). With this he called his primary
care physician who instructed him to proceed to the Emergency
Department. He reports that his ostomy output has been more
watery DISEASE but he is uncertain whether it has increased in
volume.

In the Emergency Department he was noted to have serum
sodium of 107Admission Date: [**2133-6-13**] Discharge Date: [**2133-6-29**]

Date of Birth: [**2064-9-21**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
L sided CP [**7-4**] Admission Date: [**2133-7-29**] Discharge Date: [**2133-8-10**]

Date of Birth: [**2064-9-21**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
chest pain DISEASE and shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Coronary angiogram
Intra-aortic balloon pump
Peritoneal dialysis

History of Present Illness:
68yo man w/ 3 vessel CAD s/p STEMI w/ stenting of LAD ([**5-30**])
NSTEMI w/ DES to LCx ([**6-30**]) and ESRD DISEASE on Peritoneal dialysis who
p/w chest pain DISEASE and shortness of breath DISEASE . The CP is substernal
sharp radiating to lower neck occurs both at rest & w/
activity. No palliative factors.

Past Medical History:
1. CAD (3VD s/p STEMI [**5-30**] s/p BMS to LAD complicated by
cardiogenic shock DISEASE requiring balloon pump and intubation)
**Severe cardiomyopathy DISEASE (EF 15%)
2. ESRD DISEASE [**2-26**] PCKD on PD
3. Prostate Cancer DISEASE treated with neoadjuvant hormonal therapy
followed by external beam radiation therapy
4. Anemia DISEASE of CD
5. PVD with LE claudication (on plavix)
6. H/O GIB DISEASE

Social History:
Former smoker no EtOH. Lives with his wife.


Family History:
N/C


Physical Exam:
Afebrile HR 100 BP 96/67 O2 96% on 2L NCT
Gen: alert awake oriented mild distress
HEENT: increased JVP no LAD dry oral mucosa
Pulmonary: bibasilar crackles
Cardiac: sinus tach Nml S2S2
Abd: soft Admission Date: [**2135-11-28**] Discharge Date: [**2135-12-6**]


Service:

HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is an 88 year old woman
with a history of hypertension hypercholesterolemia DISEASE and
critical aortic stenosis DISEASE referred to Dr. [**Last Name (Prefixes) **] for
replacement of her aortic valve. The patient was scheduled
for surgery on [**2135-11-1**] and on preoperative workup was found
to have a pseudomonas urinary tract infection DISEASE . Surgery was
rescheduled. Cardiac catheterization showed aortic valve
area of 0.6 centimeter squared mild to moderate mitral regurgitation DISEASE and ejection fraction of 55%.

PAST MEDICAL HISTORY:
1. Aortic stenosis.
2. Hypertension DISEASE .
3. Hypercholesterolemia DISEASE .
4. Glaucoma.
5. Irritable bowel syndrome DISEASE .
6. Gastroesophageal reflux disease DISEASE .
7. Pneumonia.
8. Status post total abdominal hysterectomy bilateral
salpingo-oophorectomy.
9. Status post appendectomy.

ALLERGIES: The patient is allergic DISEASE to Codeine which causes
facial swelling. The patient is allergic DISEASE to Celexa.

MEDICATIONS ON ADMISSION:
1. Carvedilol 3.125 mg p.o. twice a day.
2. Latanoprost 0.005% ophthalmic drops one drop both eyes
q.h.s.
3. Protonix 40 mg p.o. once daily.
4. Lipitor 20 mg p.o. once daily.

HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital1 346**] on [**2135-11-28**] and was taken to the
operating room on [**2135-11-30**] with Dr. [**Last Name (Prefixes) **] for an
aortic valve replacement with 19 millimeter pericardial
valve. Please see operative note for further details. The
patient tolerated the procedure well and was transferred to
the Intensive Care Unit in stable condition. The patient was
weaned the next day from mechanical ventilation on the first
postoperative night. Postoperatively the patient was found
to be significantly hypertensive DISEASE and started on Nipride and
Nitroglycerin as well as Lopressor. On postoperative day
number one the pulmonary artery catheter was removed. On
postoperative day number two chest tubes were removed. The
patient's oral antihypertensives were increased and by
postoperative day number three the patient was weaned off
the Nitroglycerin and transferred from the Intensive Care
Unit to the regular part of the hospital. The patient was
requiring only Tylenol for pain DISEASE relief. The patient was
evaluated by physical therapy and it was felt that the
patient would benefit from a stay at short term
rehabilitation. The patient's pacing wires were removed
without incident. By postoperative day number five the
patient was cleared for discharge to rehabilitation facility.

CONDITION ON DISCHARGE: Temperature maximum 98.4 pulse 86
sinus rhythm blood pressure 122/53 respiratory rate 16 in
room air oxygen saturation 94%. Neurologically the patient
is awake alert and oriented times three nonfocal
ambulating from bed to the bathroom without assistance.
Cardiovascular is regular rate and rhythm without rub or
murmur. Breath sounds are clear bilaterally. The abdomen is
soft nontender nondistended. The patient is tolerating
regular diet. Sternal incision is clean dry and intact and
there is no erythema DISEASE or drainage.

LABORATORY DATA: White blood cell count 11.8 hematocrit
34.3 platelet count 146000. Sodium 137 potassium 3.6
chloride 97 bicarbonate 32 blood urea nitrogen 11
creatinine 0.5 glucose 95.

MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Enteric Coated Aspirin 325 mg p.o. once daily.
3. Tylenol 650 mg every four hours p.r.n.
4. Furosemide 40 mg p.o. twice a day times seven days.
5. Potassium Chloride 20 mEq p.o. once daily times seven
days.
6. Lopressor 100 mg p.o. three times a day.
7. Captopril 50 mg p.o. three times a day.
8. Latanoprost 0.005% one drop each eye q.h.s.
9. Protonix 40 mg p.o. once daily.
10. Lipitor 20 mg p.o. once daily.

DISCHARGE STATUS: The patient is to be discharged to
rehabilitation in stable condition.

DISCHARGE DIAGNOSES:
1. Aortic stenosis.
2. Status post aortic valve replacement.
3. Hypertension DISEASE .




[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]

Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36

D: [**2135-12-5**] 18:46
T: [**2135-12-5**] 19:00
JOB#: [**Job Number 2711**]
Admission Date: [**2117-1-9**] Discharge Date: [**2117-1-19**]


Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is an 89 year old male with past medical history of
diverticulosis DISEASE and melanoma DISEASE who presented with with altered
mental status after a fall. The exact details of what happened
are a bit unclear as patient is not able to give a full history
but on [**2117-1-9**] the patient was shoveling snow when he sustained
a fall and struck his head. He managed to get inside and call
his daughter who came to check on him and found him very
confused but able to speak with blood visible outside and inside
the house. She brought the patient to the ED where he had head
CT revealing intraparenchymal and subdural hemorrhages DISEASE and
neurosurgery was consulted. They recommended no acute
neurosurgical management at the time. Patient was extremely
confused and becoming less responsive at that time so he was
emergently intubated for airway protection and admitted to the
neurosurgery ICU. Of night he had a CT of his chest abdomen
and pelvis that night which was remarkable for signs of
aspiration as well as some free air in his abdomen. His
abdominal exam was benign and surgery evaluated him feeling
there were no signs of an acute surgical abdomen or need for
intervention.

Past Medical History:
-Diverticulosis
-Melanoma R. Chest
-Cataract
-Pseudoexfoliation syndrome
-HTN
-Basal Cell CA


Social History:
Very independant care taker for his wife who has dementia DISEASE

Family History:
NC

Physical Exam:
PHYSICAL EXAM DISEASE : in NICU
O: T: af BP: 157/ 62 HR: 60 R :18 O2Sats99
Gen: WD/WN trying to sit up on the stretcher at times.
HEENT: Pupils: [**1-5**] bilaterally EOMis / no hemotympanum
noted / no csf rhinorrhea / no battles / no raccoons sign's
Neck: in cervical collar.

Neuro: gcs eAdmission Date: [**2124-6-12**] Discharge Date: [**2124-7-8**]

Date of Birth: [**2083-3-21**] Sex: M

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 301**]
Chief Complaint:
GERD DISEASE and small hiatal hernia DISEASE

Major Surgical or Invasive Procedure:
[**2124-6-12**]
Laparoscopic converted to open redo Nissen
fundoplication and repair of hiatal hernia DISEASE .
[**2124-6-16**]
Esophagogastroduodenoscopy.
[**2124-6-19**]
1. Reopening of abdomen and washout of intraperitoneal
hematoma DISEASE .
2. Endoscopy
[**2124-6-27**]
CT guided pigtail placement left pleural space
[**2124-6-27**]
CT guided drain placed in perisplenic fluid collection


History of Present Illness:
41-year-old black gentleman status post Nissen
fundoplication five years ago. He did great during this time
with no reflux or difficulty swallowing at all. He had
previously undergone endoscopic approaches to relieve his
heartburn DISEASE which had failed. However for the last two months
he has had difficulty with some reflux as well as swallowing
water. Endoscopy revealed a small hiatal hernia DISEASE and gastritis DISEASE .
A barium swallow showed a small herniation DISEASE of the GE junction
possibly above the diaphragm. He complains of these problems
with swallowing and also notes more frequent burping.


Past Medical History:
Episcleritis DISEASE bilaterally: Followed by Dr. [**Last Name (STitle) **].
GERD DISEASE s/p Nissen Fundoplication
Obesity DISEASE
Hypercholesterolemia DISEASE : Borderline in the past.
Chronically elevated liver function tests: Normal evaluation in
the past.
Chronic low back pain DISEASE
Hypertension DISEASE .
s/p distal biceps tear and repair on [**2119-9-8**] by Dr. [**Last Name (STitle) 2719**].

Social History:
The patient states that he drinks beer occasionally on the
weekends. He smokes occasional cigars but is exposed to
secondhand smoke at home. The patient smoked while he was in
military but quit over 10 years ago.


Family History:
Mother has a history of migraine headaches DISEASE . His mother has a
history of diabetes DISEASE . Uncle has a history of lung cancer DISEASE . He has
four children who are all healthy.


Physical Exam:
Vital signs

Temperature of 97.2 blood pressure 143/92 O2 sat 99% pulse
84 Resp 20 weight 236 pounds.
Breathing comfortably.
Abdomen is soft. Incision is well healed.
Moving all extremities well.


Pertinent Results:
[**2124-6-14**] UGI : No evidence of leak. Slow passage of contrast
from the esophagus into the stomach likely from edema DISEASE with
residual barium within the distal esophagus.

[**2124-6-16**] CT Abd/pelvis/CTA chest :
1. Dense right lower lobe consolidation consistent with
pneumonia DISEASE . Large
left pleural effusion DISEASE with pleural enhancementAdmission Date: [**2150-7-23**] Discharge Date: [**2150-7-31**]

Date of Birth: [**2069-12-20**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
change in mental status at home

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Pt is a 80m who was transfered from OSH after he was found to
have a large acute right sided SDH with 10mm of midline shift.
Pt was a MVA on Tuesday and was seen at [**Hospital 2725**] hospital with a
negative workup. Tonight pt was found on the floor next to his
chair at home and EMS was called.Pt had been complaining of some
dizziness DISEASE after his MVA and did have one episode of vomiting DISEASE .
Upon EMS arrival pt was reported to be awake and oriented to
self only. He appeared drowsy but answered simple questions
appropriately. Pt was taken to OSH where CT head ultimately
found a subdural hematoma DISEASE . Pt was then intubated for airway
protection and to [**Hospital1 18**] for further care.

Past Medical History:
Breast cancer DISEASE High cholesterol GERD peripheral neuropathy DISEASE
Type II DM DISEASE

Social History:
married children

Family History:
nc

Physical Exam:
T: 97.4 BP: 121/67 HR:81 R 16 O2Sats 100%
Intubated and sedated.
HEENT: Pupils: 2.5-2.0 bilateral EOMs unable to evaluate

Neuro:

Mental status: Intubated and sedated. Will follow simple
commands
in all four extremities appears to be moving symmetrically


Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light2.5 to 2.0
mm bilaterally.
VII: Face appears symetric.
VIII: Hearing intact to voice.

Motor: Moving all extremities equally and symetrically.
Sensation: Intact to light touch

Pertinent Results:
CT head shows large R sided acute SDH with maximal
thickness 1.5cm and 7mm midline shift.

Labs: Na 142 K 4.5 WBC 11.8 HCT 31.2 PLT 273 INR 1.2 PTT 20.4


Brief Hospital Course:
Pt was admitted to the ICU for close monitoring. He was given a
loading dose of fosphenytoin. He was following commands and was
able to be extubated. Repeat CT should stable appearance. He
continued to be monitored closely. It was noted that he was
unable to speak on [**7-25**] but given that there were no other
lateralizing symptoms or signs the decision was made that he
would be monitored closely. His symptoms improved over the
course of [**7-25**] and [**7-26**] and he was not taken to the OR. He
continued to have word-finding difficulty but he was able to
respond to most questions with obvious comprehension. On [**7-26**] R
wrist pain DISEASE and swelling DISEASE was noted and he was found to have a
wrist fracture DISEASE which was casted by ortho. On [**7-27**] he developed
an erythematous rash DISEASE over his lower back and flank and he was
transitioned from dilantin to keppra for seizure DISEASE prophylaxis.
His exam continued to improved. He complained of posterior neck
pain DISEASE on [**2150-7-29**] - CT of c-spine DISEASE done which showed degenerative
changes but no acute fracture DISEASE . He was evaluated by PT/OT and
felt suitable for rehab. Upon discharge he was alert and
oriented x3 only very minimally word finding issues full
motors no pronator drift following commands.

Medications on Admission:
Gemfibrozil 600 twice dailyTamoxifen 20mg daily Protonix 40mg
daily MVI 1 tab dailyZolpedin 10mg qhs Metformin unknown dose
and spiriva unknown
dose.


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

6. Pantoprazole 40 mg Tablet Delayed Release (E.C.) Sig: One
(1) Tablet Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Tiotropium Bromide 18 mcg Capsule w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore DISEASE throat.
12. Camphor-Menthol 0.5-0.5 % Lotion DISEASE Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash DISEASE .
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain DISEASE .
16. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain DISEASE .
17. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day)
as needed for muscle spasm/stiffness DISEASE .


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
Acute right subdural hematoma DISEASE


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
Admission Date: [**2138-12-2**] Discharge Date: [**2138-12-12**]

Date of Birth: [**2071-12-12**] Sex: M

Service: CARDIOTHORACIC SURGERY

HISTORY OF THE PRESENT ILLNESS: This is a 66-year-old man
with a past medical history significant for coronary artery
disease status post coronary artery bypass grafting in
[**2128-10-21**] at which time they performed a left internal
mammary artery to the left anterior descending saphenous
vein graft to the OM-I and OM-II sequential and saphenous
vein graft to the PDA. He is also status post stenting of
his saphenous vein graft to the OM-I OM-II territory in
[**2135-3-21**] and PTCA and brachytherapy to the saphenous
vein graft to the OM-I OM-II in [**2137-12-21**]. The
patient also has a past medical history significant for
insulin-dependent diabetes mellitus hypertension DISEASE
hypercholesterolemia depression DISEASE mild dementia DISEASE history of
TIA DISEASE status post bilateral carotid endarterectomies in [**2134**].

The patient is a 66-year-old male with a long-standing
history of coronary artery disease DISEASE who was admitted [**2138-12-2**] due to unstable angina DISEASE with a troponin level ranging
between 4.5 and 5.9. Cardiac catheterization was performed
on [**2138-12-2**] which revealed a patent left internal
mammary artery graft occluded OM-1 and OM-2 graft and a 90%
occlusion in the in-stented segment of the PDA. The last
echocardiogram was performed in [**2137-5-21**] which revealed a
left ventricular ejection fraction of 40%.

ADMISSION MEDICATIONS:
1. Atenolol 50 mg p.o. q.d.
2. Lipitor 40 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Aricept 5 mg p.o. q.d.
5. Zestril 20 mg p.o. q.d.
6. Metformin 850 mg b.i.d.
7. Terazosin 5 mg q.h.s.
8. Paxil 5 mg p.o. q.d.
9. Buspar 15 mg t.i.d.
10. Depakote 750 mg b.i.d.
11. Vitamin E.
12. Nitroglycerin patch.
13. Plavix which is being held.
14. NPH insulin 12 units q.a.m. 8 units q.p.m. regular
insulin 4 units q.a.m.

HOSPITAL COURSE: An off-pump redo coronary artery bypass
grafting was performed on [**2138-12-8**]. It was a
coronary artery bypass grafting times one with the saphenous
vein graft to the obtuse marginal via left thoracotomy
incision.

The patient was transferred to the Cardiac Surgery Recovery
Unit in stable condition on Neo-Synephrine at 0.6 micrograms
per kilogram per minute and propofol in normal sinus rhythm
at 57 beats per minute. He was extubated the same day of
surgery without any incidents around 6:00 p.m.

On postoperative day number one the patient had a low-grade
temperature at 100.3 in sinus rhythm at 88. The vital signs
were stable. The white count was 9.1 hematocrit 31.3
platelet count 147000 with an unremarkable physical
examination. The plan was to continue to keep his blood
pressure down on Nipride and to start the patient on his p.o.
medications as well as his p.o. diet. If able to wean off
the Nipride the plan was to transfer the patient to the
floor.

On postoperative day number two the patient was mildly
disoriented however calm without complaints with his pain DISEASE
well controlled. He was still with a low-grade temperature
of 100.1 in sinus rhythm at 88 mildly hypertensive DISEASE at
170/88. On physical examination he had mild crackles
bilaterally otherwise his examination was benign. The plan
was just to continue monitor his mental status and pain DISEASE
control.

On postoperative day number three the patient was still
without complaints however still requiring a sitter for his
disorientation. Currently afebrile. The vital signs were
stable saturating at 94% on room air. The physical
examination was benign. The plan was to go for a cardiac
catheterization this morning with a possible PTCA with plus
or minus stenting of the stenotic area.

He did undergo cardiac catheterization on [**2138-12-11**]
which now revealed a saphenous vein graft to the obtuse
marginal patent and a saphenous vein graft to the posterior
descending artery with a 90% distal stenosis with a 3 by 13
mm stent with distal protection and 0% residual with normal
flow. The plan was to continue the patient on aspirin and
Plavix 75 mg p.o. daily for 30 days and to administer
Integrelin overnight.

The anticipated date of discharge is [**2138-12-12**]. The
patient is to be discharged home on the following
medications.

DISCHARGE MEDICATIONS:
1. Metformin 850 mg p.o. b.i.d.
2. Lisinopril 2.5 mg p.o. q.d.
3. Sliding scale of insulin.
4. Metoprolol 50 mg p.o. b.i.d.
5. Divalproex 500 mg p.o. b.i.d.
6. Buspar 15 mg p.o. t.i.d.
7. Paxil 5 mg p.o. q.d.
8. Atrovastatin 40 mg p.o. q.d.
9. Plavix 75 mg p.o. q.d. for three months.
10. Donepezil 5 mg p.o. q.h.s.
11. Dulcolax milk of magnesia p.r.n.
12. Percocet 5 one to two tablets p.o. q. 4-6 hours p.r.n.
pain DISEASE .
13. NPH 3 units at breakfast 4 units at bedtime.
14. Ibuprofen 400 mg q.i.d.
15. Acetaminophen 650 mg q. four hours p.r.n.
16. Aspirin 325 mg p.o. q.d.
17. Colace 100 mg p.o. b.i.d.
18. Lasix 20 mg p.o. b.i.d.
19. Potassium chloride 20 mEq p.o. q.d.

PLAN: The plan is for the patient to arrange a follow-up
visit with Dr. [**Last Name (STitle) 1537**] in one month Dr. [**Last Name (STitle) 120**] in one month
and his primary care physician in two to four weeks.

CONDITION AT DISCHARGE: Good.

DISCHARGE DIAGNOSIS: Coronary artery disease status post
re-do off-pump coronary artery bypass grafting times one.



[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**] M.D. [**MD Number(1) 1540**]

Dictated By:[**Doctor Last Name 2011**]

MEDQUIST36

D: [**2138-12-12**] 13:20
T: [**2138-12-14**] 15:05
JOB#: [**Job Number 2012**]
Admission Date: [**2150-8-4**] Discharge Date: [**2150-8-18**]

Date of Birth: [**2069-12-20**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worsening Mental Status with known SDH

Major Surgical or Invasive Procedure:
[**2150-8-5**] Right Craniotomy and evacuation of SDH

History of Present Illness:
Mr [**Known lastname 2727**] was admitted to our service from [**Date range (1) 2728**] with a right
sided subdural hematoma DISEASE . He was treated conservatively and
monitored his mental status and word finding difficulty improved
by discharge five days ago. He has been at a rehab facility
since discharge when the staff and his family noticed that he
began to have word finding difficulty confusion DISEASE and worsening
headache DISEASE . He had an outside CT which showed increase size of
subdural so he was transferred here for further care.


Past Medical History:
Breast cancer DISEASE High cholesterol GERD peripheral neuropathy DISEASE
Type II DM DISEASE

Social History:
married children


Family History:
non-contributory

Physical Exam:
PHYSICAL EXAM DISEASE Upon Admission:
O:T 97.6 HR 66 BP 112/48 RR 14 SPO2 98% RA DISEASE
laying on stretcher. NAD. Admission Date: [**2130-11-13**] Discharge Date: [**2130-12-6**]


Service: MICU

HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
woman with a history of congestive heart failure DISEASE peripheral
vascular disease DISEASE Type 2 diabetes mellitus DISEASE and Parkinson's DISEASE
disease who was admitted after being found unresponsive at
home. The patient was in her usual state of health until 1
P.M. on the day of admission when she was found by her
cousin who lives with her. The patient was unresponsive
apparently no longer than 30 seconds. She slumped forward
and EMS was called. There were no preceding palpitations DISEASE
shortness of breath chest pain DISEASE focal weakness dysarthria DISEASE
bowel or bladder incontinence DISEASE or seizure DISEASE activity noted.
EMS noted the patient to have a finger stick blood glucose of
240 atrial fibrillation DISEASE on the monitor with a rate of 100
blood pressure of 136/palp respiration rate of 4 and
initially unresponsive. Her pupils were equal round and
reactive to light.

The patient was intubated and during intubation she was
noted to have increased agitation DISEASE . She was given 2 mg of
Versed successfully intubated and sent to [**Hospital1 346**] where she was immediately brought
to the Medical Intensive Care Unit. Upon arrival she was
hemodynamically stable.

PAST MEDICAL HISTORY:
1. Congestive heart failure DISEASE last echocardiogram in [**2130-8-14**] showed mild symmetric left ventricular hypertrophy
an ejection fraction of greater than 55% and 1Admission Date: [**2118-7-28**] Discharge Date: [**2118-8-1**]

Date of Birth: [**2066-5-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
[**7-29**] pericardiocentesis DISEASE

History of Present Illness:
This is a 52 year old female with PMHx of hyperlipidemia DISEASE who
presents to the CCU tonight after her PCP sent her to [**Hospital1 18**]
Emergency department for an enlarged heart on CXR.

The patient's history begins about 5 weeks ago when she
experienced left anterior chaest pain which woke her around 0500
that mornig. Pain DISEASE is worse with breathing and radiated into her
left arm and left side of the neck. She went to [**Hospital3 2737**]
(which records were obtained) and had an MI workup including 2
sets of negative cardiac enzymes a negative stress test and an
unremarkable echo. She also with CT scan for r/o PE which found
a 5 mm nodule in the RUL but not other findings. Patient was
discharged from the hospital with no clear diagnosis. Prior to
onset of symptoms she denied any recent local or foreign travel
or cough/cold symptoms.

Patient continued to have chest pain DISEASE over the next month.
Earlier this week she started having fevers chills DISEASE and night
sweats. Temperature taken at home was max 100.8. She did
experience some SOB and nausea DISEASE but no vomiting DISEASE . She presented
to an OSH where she refused labs as she had already undergone
workup and was discharged with a Zpack. She noted continued
symptoms and decided to see her PCP today who ordered a CXR and
saw cardiomegaly DISEASE pleural and pericardial effusion DISEASE and sent her
to the ED.

In the ED initial vitals were 18:04 8 99.2 106 116/72 20 97%.
She was having [**8-12**] pain DISEASE worse while lying supine and relieved
sitting upright. Pt states pain DISEASE in chest neck upper abdomen DISEASE
and upper back. Pt with some sob with exersion. Patient given
toradol IV and Zosyn 1L NS fentanyl. Pulses done at bedside
by cardiology fellow which revealed only 10 mmHg. Bedside echo
showed moderate to large pericardial effusion DISEASE with right atrial
diastolic collapse and impaired R ventricular DISEASE filling upon
inspiration.
.
On arrival to the CCU patient has an aching pain DISEASE [**8-12**] with
family at the bedside.
.
REVIEW OF SYSTEMS
On review of systems s/he denies any prior history of stroke DISEASE
TIA DISEASE deep venous thrombosis pulmonary embolism bleeding DISEASE at the
time of surgery myalgias DISEASE joint pains cough hemoptysis DISEASE black
stools or red stools. S/he denies exertional buttock DISEASE or calf
pain DISEASE . All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain DISEASE
dyspnea DISEASE on exertion paroxysmal nocturnal dyspnea orthopnea DISEASE
ankle edema palpitations syncope DISEASE or presyncope DISEASE .


Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes Dyslipidemia Hypertension DISEASE
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-Intimal thickening in R carotid artery
Hystectomy for fibroids DISEASE
Hemorrhoids recent negative colonoscopy 5 years ago
Mammogram one month prior- normal
.
MEDICATIONS:
Pravastatin 40mg daily
Docusate sodium 100 mg daily
Lactobacillus Rhamnosus Gg 1 capsule daily DISEASE

ALLERGIES: NKDA


Social History:
-Tobacco history: none
-ETOH: occasional
-Illicit drugs: none
-Works for shoe store in inventory moving boxes

Family History:
FAMILY HISTORY:
Family history of CAD in grandparents at older age. Breast
cancer DISEASE in grandmother and pancreatic cancer DISEASE in another relative
.

Physical Exam:
PHYSICAL EXAMINATION:
VS: TAdmission Date: [**2165-5-14**] Discharge Date: [**2165-5-17**]


Service: MEDICINE

Allergies DISEASE :
IodineAdmission Date: [**2168-12-3**] Discharge Date: [**2168-12-14**]


Service: MEDICINE

Allergies DISEASE :
IodineAdmission Date: [**2169-2-13**] Discharge Date: [**2169-3-2**] Service: MEDICINE

Allergies DISEASE :
Iodine-Iodine Containing / Ampicillin / Phenergan Plain /
Zaroxolyn / Ambien

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
Ms. [**Known lastname 2749**] is a [**Age over 90 **]yoF with severe diastolic HF NYHA class IV
with multiple exacerbations DISEASE in past year HTN DISEASE HLD Afib DISEASE and
gait abnormality related to Admission Date: [**2164-11-21**] Discharge Date: [**2165-1-1**]

Date of Birth: Sex: F

Service:

HISTORY OF PRESENT ILLNESS: Ms. [**Name14 (STitle) 2765**] is a 63-year-old
lady who was initially admitted to the Medical service at
[**Hospital6 256**] after being transferred
from an outside hospital.

She has a long history of end-stage renal disease DISEASE and is
status post cadaveric kidney transplant. She has recently
been diagnosed with gastric B cell lymphoma DISEASE and presents here
for further workup. This was prompted by symptoms of
abdominal pain DISEASE and diagnosed after EGD-obtained biopsy. She
has had a history of weight loss DISEASE night sweats pruritus DISEASE and
feeling fatigued over the last few months.

PAST MEDICAL HISTORY:
1. Underwent cadaveric renal transplantation in [**5-/2156**] for
end-stage renal disease DISEASE secondary to hypertension DISEASE .
2. Osteoporosis.
3. Total abdominal hysterectomy with bilateral
salpingo-oophorectomy.
4. Peripheral vascular disease DISEASE and was scheduled to undergo
peripheral vascular bypass.
5. Congestive heart failure DISEASE .
6. Appendectomy.
7. Lumbar disc surgery.

PHYSICAL EXAMINATION: She is an elderly lady in some
distress. She is afebrile. Blood pressure is 100/70 heart
rate is 96. Chest and abdomen are clear to auscultation.
Abdomen is distended and somewhat tender. Extremities are
within normal limits.

HOSPITAL COURSE: She was admitted to the hospital for
further management. During the next 24 hours her abdominal
pain DISEASE and tenderness DISEASE worsened. Nasogastric tube was placed
for decompression. After CAT scan and surgical evaluation it
was decided that she had an acute abdomen and we decided to
do a laparotomy.

On the laparotomy she was found to have extensive ganglion of
her small bowel DISEASE . Most of her small bowel was resected and
an SMA DISEASE thrombectomy was performed by the Vascular Surgery
service at the same time. A second-look laparotomy was
performed the next day and more small bowel resected. Two
days later a third look was performed and small bowel
reanastomosed. This left her with about 50 cm of small
intestine.

She was kept in the Intensive Care Unit postoperatively and
extensive discussions were had with the family and her poor
prognosis explained to them. She was kept on total
parenteral nutrition and low-dose immunosuppression.
Hematology/Oncology consultation was obtained and it was
felt she was not stable enough to tolerate treatment for her
lymphoma. She briefly developed peritonitis DISEASE which resolved
with antibiotic therapy. She was gradually started on orals
which she tolerated surprisingly well. She was also able to
take all of her oral medication. As expected we were not
able to wean her off the TPN.

She continued to be followed by the Renal and
Hematology/Oncology and Transplant services during this
admission.

Finally due to lack of improvement in her condition and as
per her and the family's wishes she was transferred to
Hospice care.

DISPOSITION: Transferred for palliative Hospice care.

DISCHARGE DIAGNOSES:
1. Acute mesenteric ischemia DISEASE .
2. End-stage renal disease DISEASE .
3. Hypertension DISEASE .
4. Gastric B cell lymphoma.
5. Status post cadaveric kidney transplant.




[**Name6 (MD) 1344**] [**Name8 (MD) 1345**] M.D.

Dictated By:[**Name8 (MD) 2766**]

MEDQUIST36

D: [**2165-4-1**] 16:18
T: [**2165-4-3**] 22:38
JOB#: [**Job Number 2767**]
Admission Date: [**2114-12-10**] Discharge Date: [**2114-12-18**]

Date of Birth: [**2071-11-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Bactrim / Baclofen

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
fevers headache diarrhea hypoxia DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The paitent is a 43-year-old male with a longstanding history of
HIV/AIDS who presented to the ED after a week long history of
high grade fevers DISEASE and worseing dyspnea DISEASE with exertion. The
patient was diagnosed in [**2095**] with HIV and has been on and off
HAART therapy since that time. Most recently he was on steady
treatment for 3 years until this spring when he decided to take
a self decided medication holiday. He reports he has not taken
HAART medications in about 6 months. About 2-3 months ago the
patient also started having watery diarrhea DISEASE intermittently [**2-18**]
times weekly. About one and a half weeks ago he started
noticing high fevers DISEASE and night sweats. The diarrhea DISEASE worsened and
instead of having it on and off it became constant. The fevers DISEASE
also continued to worsen and peaked at a temp of 103.6 today
the morning of his admission. Two days prior to admission he
started noticing shortness of breath DISEASE with simple tasks such s
climbing a few stairs at home. He also describes a
non-productive dry cough DISEASE and some chest Admission Date: [**2130-4-6**] Discharge Date: [**2130-4-13**]

Date of Birth: [**2054-8-29**] Sex: M

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Acute Paralysis

Major Surgical or Invasive Procedure:
None

History of Present Illness:
75yo Korean gentleman awoke this morning talked to the bathroom
and felt sudden onset back and abdominal pain DISEASE after which he
lost functioning of bilateral lower extremeties. Taken to OSH
where abdominal CT scan thought to show dissection of thoracic
AAA Pt xferred to [**Hospital1 18**] for possible surgical
intervention but on review of outside CT no aneurismal rupture DISEASE
noted.

Past Medical History:
GERD
HTN DISEASE

Social History:
Previously heavy smoker quit 1.5 yrs ago.
no alcohol


Family History:
non contributary

Physical Exam:
VS: afeb 130/60 72
General: WNWD NAD
HEENT: Anicteric MMM without lesions OP clear
Neck: Supple no LAD no carotid bruits DISEASE no thyromegaly DISEASE
CV: RRR s1s2 no m/r/g
Resp: CTAB no r/w/r
Abd: Soft/distended
Ext: No c/c/e distal pulses intact
Skin: No rashes petechiae DISEASE

MS: A&O x 3 interactive appropriate following all commands
Speech fluent w/o paraphasic errors [** **] Date: [**2123-1-12**] Discharge Date: [**2123-1-19**]

Date of Birth: [**2048-3-13**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Desmopressin

Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
hyponatremia DISEASE

Major Surgical or Invasive Procedure:
endoscopy - EGD with EUS [**First Name3 (LF) 2792**]


History of Present Illness:
74F the patient w/ hx of PE hyponatremia breast CA HTN DISEASE states
that she was sent in by her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **].
The patient has a colonscopy on Wednesday (today) to evaluate
for a possible cause of the patient's stool incontinence DISEASE .
Otherwise the patient does state that she has been drinking a
bit more fluids for upcoming [**Last Name (Titles) 2792**] (but stopped after PCP
coverage told her to come into the hospital and has not taken
the bowel prep yet). Otherwise the patient is not having any
chest pain DISEASE or shortness of breath DISEASE . The patient is not having any
symptoms that are new or acute. Pt has persistent stool
incontinence DISEASE . The patient notes that she has had 6 BMs in the
past 24 hrs and usually has a number of loose BMs per day. No
CP SOB palpitations cramps joint pain DISEASE . No headaches DISEASE .
.
In the ED inital vitals were 96.7 76 128/58 20 94%
No symptoms. Nothing remarkable on exam. Patient's Na decreased
from 119 --Admission Date: [**2193-5-30**] Discharge Date: [**2193-5-31**]

Date of Birth: [**2151-9-14**] Sex: M

Service: MED


HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old
male with a longstanding history of seizure disorder DISEASE and
mental retardation who presented to the Emergency Room with a
possible asthma DISEASE exacerbation as well as some right arm
shaking. The patient has a longstanding seizure disorder DISEASE by
report both GTC and complex partial. The patient's seizures DISEASE
have been relatively well controlled for the past year up to
a few weeks ago. The patient did have an episode of
unresponsiveness thought to be a postictal state. He was
recently admitted on [**2193-5-24**] at [**Hospital6 649**] for asthma DISEASE exacerbation. He was seen by
Neurology at that time for questioned seizure DISEASE activity. His
Keppra was increased during that hospitalization from 5000
b.i.d. to 2000 b.i.d.

On the morning of admission the patient was found by EMS to
have an O2 saturation in the 80s and appeared apneic DISEASE . It was
felt that he again was having an asthmatic exacerbation DISEASE . He
was intubated in the field and brought to [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. At [**Hospital6 2018**] he was noted to have some right arm shaking which
was felt to be a seizure DISEASE episode. He received 8 mg of Ativan
and was placed on propofol. He was also noted to have some
teeth chattering.

PAST MEDICAL HISTORY: Seizure disorder.

Anoxic DISEASE brain injury.

Asthma.

Depression DISEASE .

Fetal alcohol syndrome.

Cervical fracture DISEASE .

FAMILY HISTORY: No seizure disorders DISEASE .

SOCIAL HISTORY: Lives in group home with 24 hour
supervision. No smoking or drinking history.

MEDICATIONS ON ADMISSION:
1. Depakote 500 mg p.o. t.i.d.
2. Keppra 2000 mg p.o. b.i.d.
3. Valium 5 mg p.o. b.i.d.
4. Neurontin 800 mg t.i.d.
5. Celexa 40 mg p.o. q d.
6. Albuterol nebulizer.
7. Colace 100 mg p.o. b.i.d.
8. Pseudoephedrine 30 mg p.o. q.i.d.


ALLERGIES: Phenobarbital phenytoin penicillin Haldol.

PHYSICAL EXAMINATION: Vital signs: Temperature 100.0 heart
rate 76 blood pressure 132/77 saturation of 100 percent on
vent assist control/650/20/5 on 85 percent not
overbreathing PIP-31. General: Intubated sedated male
appearing slightly rigid. HEENT: Pupils were 2 cm minimally
reactive to light. Lungs: Expiratory wheezes bilaterally.
Cardiovascular: Regular rate and rhythm. No murmurs rubs or
gallops. Abdomen: Soft nontender nondistended normoactive
bowel sounds. Extremities: No cyanosis clubbing DISEASE or edema DISEASE
2Admission Date: [**2179-7-22**] Discharge Date: [**2179-7-24**]

Date of Birth: [**2128-5-8**] Sex: M

Service: CCU

HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
male with no significant past medical history other than
hypertriglyceridemia DISEASE low HDL and tobacco abuse who presents
with ST elevation myocardial infarction DISEASE .

The morning of admission he woke up at 6:15 a.m. and felt
unwell with mild upper chest discomfort at rest. He had no
dyspnea DISEASE on exertion nor shortness of breath DISEASE . He went to
work had continued discomfort and at noon developed frank
upper chest pain DISEASE with radiation to both arms mild dyspnea DISEASE
though no nausea vomiting DISEASE or diaphoresis DISEASE .

He was brought to the [**Hospital1 69**]
where electrocardiogram showed inferior ST segment elevation
and he was transferred emergently to cardiac catheterization.
He was enrolled in the Cool Myocardial infarction DISEASE Study and
randomized to the cooling arm.

Left heart catheterization showed discrete 100% lesion at the
right coronary artery with timi one flow. Percutaneous
transluminal coronary angioplasty was performed and 3.5 by 13
millimeter stent was employed following which repeat
percutaneous transluminal coronary angioplasty was performed.
Repeat angiography showed residual stenosis proximal to the
stent. Therefore repeat percutaneous transluminal coronary
angioplasty was done and repeat angiography done showed
complete resolution of the lesion. He also had a 70% lesion
at the second obtuse marginal that was not treated. Left
ventriculogram showed inferior hypokinesis DISEASE and ejection
fraction of 42% normal aortic and mitral valves. The right
heart catheterization showed mean right atrial pressure of
16 pulmonary artery pressure of 49/25 and a mean pulmonary
capillary wedge pressure of 15. The patient was transiently
bradycardic and Atropine was given with good results. He was
admitted to the CCU in order to continue the cool myocardial
infarction DISEASE protocol.

PAST MEDICAL HISTORY:
1. Hypercholesterolemia. In [**2179-2-9**] total cholesterol
was 238 triglycerides 728 DISEASE LDL 118 and HDL 29.
2. Primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 2809**] [**Telephone/Fax (1) 2810**].

MEDICATIONS ON ADMISSION: None.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: The patient is a former EMT. He smokes one
half pack per day approximately thirty pack year history.
No alcohol.

FAMILY HISTORY: The patient's father and many in his
father's family have coronary artery disease DISEASE but no report of
early death DISEASE .

PHYSICAL EXAMINATION: On admission temperature is 34.6
(cooling was in place) heart rate 87 blood pressure 106/56
respiratory rate 15 oxygen saturation 97%. In general he
was alert in no acute distress. Head eyes ears nose and
throat - The pupils are equal round and reactive to light
and accommodation. Extraocular movements DISEASE are intact.
Sclerae DISEASE anicteric. The neck is supple with no
lymphadenopathy DISEASE . Jugular venous pressure is not visible.
Chest is clear to auscultation anteriorly. Cardiovascular is
regular rate and rhythm no murmurs rubs or gallops. Normal
S1 and S2 no S3 no S4. The abdomen is soft nontender
nondistended positive bowel sounds. Groin sheaths in place
no hematoma DISEASE noted no bruit. Extremities no cyanosis DISEASE
clubbing DISEASE or edema DISEASE 2Admission Date: [**2125-8-31**] Discharge Date: [**2125-9-5**]

Date of Birth: [**2052-4-11**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Codeine / Oxycodone/Acetaminophen / Morphine Sulfate

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
dyspnea fatigue DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Ms. [**Known lastname 2816**] is a 73 year old female s/p liver [**Known lastname **] for
cryptogenic cirrhosis DISEASE in [**2121**] complicated by post-[**Year (4 digits) **]
lymphoproliferative disease DISEASE s/p R-CHOP with [**Doctor First Name **] at present and
moderate pulmonary fibrosis DISEASE admitted for lower extremity
swelling DISEASE increased work of breathing and generalized weakness DISEASE .

.
In the ED she was noted to have a equivocal UA though denied
urinary frequency or dysuria DISEASE though she did report an episode of
urinary incontinence DISEASE . She had a CXR that showed possible RLL
Pneumonia DISEASE . She was given Vancomycin and Levaquin for UTI DISEASE and
PNA. She was noted to have a BP of 94/66 and HR of 140 that
improved to 120 with fluids.
.
On review of systems patient reports increased leg swelling DISEASE and
difficulty. Patient unable to state ifthere is a difference in
her oxygen tolerance. No SOB at rest. No change in 3 pillow
orthopnea DISEASE no PND.

Past Medical History:
Interstitial pulmonary fibrosis DISEASE home oxygen dependent 2-2.5L NC
S/p Liver [**Doctor First Name **] [**4-26**] for cryptogenic cirrhosis DISEASE
Post-[**Month/Year (2) **] lymphoproliferative disorder DISEASE s/p CHOP and
rituximab
Type 2 DM
HTN DISEASE
Hypothyroidism DISEASE

Social History:
Married previously lived at home but recently discharged to
rehab. Denies tobacco use.


Family History:
There is no family history of premature coronary artery disease DISEASE
or sudden death DISEASE . Afib DISEASE in sister

Physical Exam:
VS: T 96.7 HR 121 BP 135/65 RR 27 91% on 4LNC
Gen: chronically ill appearing obese famale
HEENT: facial hair tachypneic unable to speak in full
sentences
CV: Tachycardic regular no m/r/g
Pulm: crackles diffusely no wheezes
Abd: obese soft NT ND bowel sounds present
Ext: trace peripheral edema DISEASE b/l
Neuro: CNs [**2-6**] intact moving all extremities

Pertinent Results:
Imaging:
[**2125-8-31**]. CXR.
IMPRESSION:
Possible superimposed right middle lung field infection DISEASE on
background of pulmonary fibrosis DISEASE .
.
Chest CT. [**2125-7-10**].
IMPRESSION:
1. Minimal improvement in moderately severe generalized
interstitial lung disease DISEASE . Persistent air trapping. No evidence
of pulmonary hypertension intrathoracic malignancy DISEASE or
infection DISEASE .
2. Longstanding pneumobilia DISEASE .
.
PFTs [**2125-7-5**].
Mechanics: The FVC is markedly reduced. The FEV1 is moderately
to markedly reduced. The FEV1/FVC ratio is elevated.
Flow-Volume Loop: Marked restrictive pattern.
.
Impression:
Results are consistent with a restrictive ventilatory defect
which is confirmed by the markedly reduced TLC DISEASE measured on
[**2125-3-21**]. Compared to the prior study of [**2125-5-17**] there has
been no significant change.
.
Echo [**2125-3-9**].
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is no ventricular septal defect DISEASE . The right
ventricular cavity is markedly dilated with depressed DISEASE free wall
contractility. The ascending aorta is moderately dilated. There
are focal calcifications DISEASE in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis DISEASE is not
present. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse DISEASE . The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic DISEASE
hypertension DISEASE . The main pulmonary artery is dilated. The branch
pulmonary arteries are dilated. There is no pericardial
effusion.

Compared with the findings of the prior study (images reviewed)
of [**2125-1-22**] the right ventricle is markedly dilated.
.
Admit labs
137 Admission Date: [**2125-12-10**] Discharge Date: [**2125-12-25**]

Date of Birth: [**2052-4-11**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Codeine / Oxycodone/Acetaminophen / Morphine Sulfate

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Hypercarbic respiratory failure DISEASE

Major Surgical or Invasive Procedure:
Endotracheal intubation
PICC line placement

History of Present Illness:
Ms. [**Known lastname 2816**] is a 73 yo female with PMH significant for ILD DISEASE on
[**1-27**].5L home O2 diastolic CHF cor pulmonale s/p liver
[**Date Range **] on immunosuppression post-[**Date Range **]
myeloproliferative disorder DISEASE s/p CHOP and rituximab who was
initially admitted to hospital after a mechanical fall for pain DISEASE
control who is now being transferred to the MICU for
hypercarbic/hypoxic respiratory failure DISEASE in the setting of
emesis DISEASE . Patient was initially admitted to the medicine service
on [**12-10**] for a mechanical fall. She stated that prior to her
fall she was in her USOH without any change in her baseline
respiratory status or other new symptoms. She stepped on her
scale and then lost her balance and landed on her low back. She
was then brought to [**Hospital1 18**] ED. There was no head trauma DISEASE or LOC by
report. Here spine films revealed no acute fracture. She was
being treated with PT and pain DISEASE control. She was not receiving
any opiates due to underlying lung disease DISEASE . She did received
tylenol ibuprofen and lidoderm patch.
.
Yesterday evening the patient triggered after an episode of
nausea DISEASE and vomiting DISEASE as well as a drop in her O2 saturation.
Changed to face mask with improvement in O2. She remained
hemodynamically stable. No CXR or ABG was performed. Changed to
40% ventimask and satting in mid-90s. At 10:30 this am looks
ashen cyanotic DISEASE and lethargic on 4 L of 50% venti. O2 in high
70s at that time. Sleepy but arousable. Increased O2 to 15L on
50% ventimask. Given nebs. On exam tight air movement and
cracklie but not significantly different from baseline. Initial
gas 7.29/97/113 on 15L 50% ventimask. Last ABG in system
7.43/47/73 in 3/[**2124**]. Mental status improved with increase in
oxygenation. She was given solumedrol 100 mg IV Q8H. Reevaluated
in 1 hr still lethargic but arousable. Repeat ABG 7.28/108/79
on 15L 50% ventimask. CXR performed on floor showed some
diffuse fluffiness. She received 40 mg IV lasix. She continues
to have intermittent nausea and vomiting DISEASE with 2-3 episodes of
emesis DISEASE since yesterday evening.
.
n the MICU she was intubated on [**12-12**] for worsening
hypercarbia DISEASE . That evening she spiked a fever DISEASE went into AF vs
MAT with HRs into the 160s and hypotension DISEASE to the 80s. She did
not tolerate beta blockers at that time and was started on an
amiodarone gtt. She was also started on empiric vancomycin and
zosyn for possible aspiration pna. She received aggressive
volume resuscitation and converted to NSR the following morning.
Her amiodarone was discontinued given concern for worsening lung
and liver disease DISEASE . Her beta blocker was uptitrated. Antibiotics
were briefly discontinued on [**12-14**] and restarted on [**12-15**]. She
was eventually diuresed and was able to be extubated on [**12-16**].
She was called out to the medical floor on [**12-17**].
.
While on the medical floor she was continued on vancomycin and
zosyn for presumed aspiration pna. She had no microbiology data
to help guide therapy. She was continued on diuretics but has
run I/O even per documentation. While on floor SBPOs 100s HRs
80s RR 20s O2 90s on 3LNC.
.
On the evening of transfer trigger called for increased work of
breathing. Upon floor evaluation patient denied any subjective
SOB. O2 requirement the same at 90s n 3LNC and no significant
change in RR. However at Admission Date: [**2115-12-29**] Discharge Date: [**2116-1-29**]

Date of Birth: [**2060-12-23**] Sex: F

Service: SURGERY

Allergies DISEASE :
Morphine / Oxycodone / Penicillins / Sulfonamides / Vancomycin
And Derivatives / Ibuprofen / Dolobid / Naproxen / Clindamycin
Hcl

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Necrotizing Pancreatitis DISEASE
Cholelithiasis DISEASE

Major Surgical or Invasive Procedure:
OR [**12-30**]: Exploratory laparotomy open cholecystectomy
intraoperative cholangiogram common bile duct exploration with
choledochoscopy Pancreatic necrosectomy with wide external
drainage transgastric feeding jejunostomy.
IR [**1-16**]: CT drainage of panc collection w/pigtail placed


History of Present Illness:
55F was admitted to [**Hospital3 417**] with mental status changes
and weakness 5 days ago. Of note she has chronic abdominal pain DISEASE
form IBS DISEASE and chronic bony pain DISEASE from multiple hips replacements
and rheumatoid arthritis DISEASE . She got a CT today to
complete her workup which demonstrated severe necrotizing DISEASE
pancreatitis DISEASE with gas filled abscess. Here she complains of
[**11-19**] abdominal pain DISEASE . Denies DISEASE any n/v/d/c/CP/SOB. Per OSH notes
her LFTs have all normalized her last INR was 1.6 and her WBC
on admission was 20.


Past Medical History:
RA IBS GERD DISEASE multiple hip replacments


Social History:
Pt was married for 22 years. Her husband past away recently. She
is unable to work secondary to pain DISEASE and her rheumatoid DISEASE
arthritis DISEASE .

Family History:
Non-contributory

Physical Exam:
PE: 97.4 113 127/69 95%RA
NAD AOX3
no scleral icterus DISEASE no rashes
CTAB
RRR
distended soft diffusely tender mild guarding no rebound
no c/c/e
guiac neg


Pertinent Results:
[**2115-12-30**] 12:10AM BLOOD WBC-31.0*# RBC-4.14* Hgb-12.0# Hct-34.6*#
MCV-84 MCH-29.0 MCHC-34.7 RDW-15.5 Plt Ct-298
[**2115-12-30**] 12:10AM BLOOD PT-24.1* PTT-35.0 INR(PT)-2.3*
[**2115-12-30**] 12:10AM BLOOD Glucose-59* UreaN-11 Creat-0.6 Na-137
K-2.8* Cl-99 HCO3-27 AnGap-14
[**2115-12-30**] 12:10AM BLOOD Albumin-2.2* Calcium-7.8* Phos-3.5 Mg-2.4
Iron-19*
[**2115-12-30**] 12:40AM BLOOD Type-ART pO2-96 pCO2-35 pH-7.48*
calTCO2-27 Base XS-2
[**2115-12-30**] 12:40AM BLOOD Lactate-1.2
[**2115-12-30**] 12:10AM BLOOD ALT-20 AST-34 AlkPhos-121* Amylase-183*
TotBili-0.8 DISEASE
[**2115-12-30**] 12:10AM BLOOD Lipase-73*
[**2115-12-30**] 10:06PM BLOOD ALT-33 AST-101* LD(LDH)-429* AlkPhos-161*
Amylase-131* TotBili-4.7*

PATH:
Gallbladder choLecystectomy: Chronic cholecystitis DISEASE and
cholelithiasis DISEASE .

Abd Xray [**12-30**]:
IMPRESSION: No foreign object resembling the imaged item is
identified in the radiograph field. Please note that the right
lateral abdomen and the dome of the liver have been excluded
from the field of view.

Chest Xray [**1-1**]:
IMPRESSION: AP chest compared to [**12-30**] through 20:
Moderate left pleural effusion DISEASE is larger. Small right pleural
effusion
persists right basal atelectasis DISEASE is improved. Left lung base is
obscured
probably severely atelectatic DISEASE . Heart size is top normal and
unchanged.
Mediastinal veins slightly engorged. No pulmonary edema DISEASE . No
pneumothorax DISEASE .
ET tube left subclavian central venous line and nasogastric
tube in standard placements.

Chest Xray [**1-2**]:
No pneumothorax DISEASE . Decrease in left pleural effusion DISEASE . Bibasilar
retrocardiac
atelectasis DISEASE . No edema DISEASE .

Chest Xray [**1-5**]:
IMPRESSION: PA and lateral chest compared to [**1-2**]:
Left lower lobe consolidation is improving probably resolving
atelectasis DISEASE . Small bilateral pleural effusions DISEASE probably
unchanged. Right lung grossly clear. Heart size normal. Left
subclavian line ends at the junction of the brachiocephalic
veins. Skin staples and drains noted in the upper midline
abdomen and right upper quadrant.

Chest Xray [**1-15**]:
Improvement in left lower lobe retrocardiac atelectasis

ERCP [**1-13**]:
Contrast extravasation from the pancreatic duct.
Nonvisualization
of the pancreatic duct within the body and the tail.

CT Abdomen [**1-14**]:
No extraluminal contrast identified on non-contrast images. No
active extravasation on arterial or venous phase imaging.
Large multiloculated peripancreatic collection with gas and
multiple smaller collections associated with the pancreas. A
medial catheter courses through a portion of the dominant
peripancreatic collection. The visualized pancreatic parenchyma
enhances normally however due to the close association with
the low-density peripancreatic fluid collection pancreatic
necrosis DISEASE cannot be excluded. Attenuation of the splenic vein
which remains patent

CT Guided Drainage [**1-16**]:
Successful placement of 8 French pigtail drainage catheter into
left
lateral aspect of peripancreatic collection. Overall decreased
size of peripancreatic collection compared to two days earlier
with near resolution of the lateral portion following today's
drainage.

CT Abdomen & Pelvis [**1-22**]:
Slight decrease in peripancreatic collections since [**2116-1-16**]


Brief Hospital Course:
Ms. [**Known lastname 2818**] was transferred from an OSH to [**Hospital1 18**] for
further management of her necrotizing pancreatitis DISEASE . She was
placed in the SICU and was aggressively resuscitated with IVF
and placed on broad spectrum Abx. She was also noted to have a
markedly elevated INR and was reversed with Vitamin K and FFP.
She was closely monitored overnight and taken to the OR with
Drs. [**First Name (STitle) 2819**] and [**Name5 (PTitle) **] the next morning. She toleratd the
procedure well and taken back to the SICU postoperatively.

She remained intubated and sedated and on pressors. She came off
her pressors on POD 2 and was extubated on POD 3. She remained
in the SICU until POD 4 when she was transferrred to the floor.

-CVS: Pt rate and rhythm monitored on telemetry. She has been
persistently tachycardic in sinus rhythm controlled with beta
blockade which she will continue on discharge to rehab.

-RESP: Incentive spirometry encouraged during hospital stay.

-GI: OR for pancreatic debridement as above nutrition provided
via J-tube and PO as described below. Post-op constipation DISEASE
treated with aggressive bowel DISEASE regimen which she will continue
as an outpatient. CDiff toxin was negative on [**1-6**] and [**1-20**]

-GU: Foley catheter was removed [**1-9**] and pt was able to void
without difficulty. Urine cultures were negative [**12-30**] and [**1-14**].

-NEURO: Pain DISEASE was controlled on the floor with a dilaudid PCA
and when pt started taking PO changed to PO dilaudid.

-ACTIVITY: Pt worked with Physical Therapy on the floor. She
did have pain DISEASE with activity secondary to her Rheumatoid DISEASE
Arthritis DISEASE but was able to walk with assistance.

-F/E/N: Electrolytes were monitored and repleted regularly. Pt
maintained on tube feeds while recovering from surgery. Diet
was advanced slowly as tolerated and tube feed were stopped when
pt was taking adequate PO.

-ID: Pt was treated with empiric antibiotics post-operatively
until culture and sensitivity data was available. Her positive
cultures were: Pan-sensitive E.Coli from OR culture of
pancreatic abscess DISEASE on [**12-30**] MRSA from IR culture of pancreatic
abscess on [**1-16**] MRSA on culture from biliary drain on [**1-21**].
Antibiotic therapy during her hospital stay was as follows:
Fluconazole ([**Date range (1) 2820**])Admission Date: [**2151-2-21**] Discharge Date: [**2151-3-19**]

Date of Birth: [**2084-2-28**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
[**2-23**] Redo sternotomy CABG x 2 MVRepair (#26 annuloplasty band)


History of Present Illness:
66 yo M admitted preoperatively.

Past Medical History:
CAD s/p CABGx2 [**2124**] PPM multiple PCI NIDDM DISEASE GERD s/p dilation
of esophageal stricture DISEASE proxysmal A.fib HTN DISEASE

Social History:
retired communications technician


Physical Exam:
NAD
Admission exam unremarkable

Brief Hospital Course:
Mr. [**Known lastname 2487**] was admitted on [**2151-2-21**]. He remained on heparin and
nitroglycerin until he was taken to the operating room on
[**2151-2-23**] where he underwent a redo sternotomy CABG x 2 and MV
repair. He was transferred to the SICU in critical but stable
condition on propofol insulin epinephrine levophed
milrinone vasopressin. He was seen by electrophysiology for his
permenant pacer as well as for atrial fibrillation DISEASE with pressor
dependency. He was started on amiodarone. His IABP was removed
on POD #2. He was started on heparin for a fib. He was started
on tube feeds. He was seen by heart failure DISEASE who recommended
TEE/cardioversion and he was cardioverted successfully but he
reverted to a fib. He remained in the ICU on inotropes and
pressors for many days. They were slowly weaned off with stable
hemodynamics. Bilateral chest tubes were placed for large
effusions. On [**3-6**] he was extubated. His milrinone was weaned
to off. On [**3-11**] he was seen by vascular surgery for R flank and
RLQ pain DISEASE with a hematacrit and BP drop retroperitoneal bleed DISEASE
was found on CT scan his heparin was stopped and he was
transfused. His creatinine rose to 3.0 after the bleed DISEASE and
stabilized at 1.6. Anticoagulation was stopped and his
hematocrit stabilized without further intervention.
He was transferred to the floor on POD #20. His creatinine rose
to 1.6 but has remained there. His Lasix was decreased due to
his creatinine. He'd had a persistent small right apical
pneumothorax DISEASE which was unchanged with his pleural chest tube on
suction water seal or clamped. It was therefore removed and
his post-removal chest x-ray showed no change. His
hemodynamics and respiratory status have remained stable his
oxygen saturation on room air is 94-95% and he is ready to be
discharged home today.

Medications on Admission:
lisinopril asa zocor reglan protonix toprol actos
glucotrol plavix

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet Delayed Release (E.C.) Sig: One (1)
Tablet Delayed Release (E.C.) PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet Delayed Release (E.C.) Sig: One
(1) Tablet Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet Delayed Release (E.C.)(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 6 days: then 200 mg daily until discontinued by Dr.
[**Last Name (STitle) 1295**].
Disp:*40 Tablet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain DISEASE .
Disp:*30 Tablet(s)* Refills:*0*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
Units Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
Units Subcutaneous once a day.
Disp:*1 vial* Refills:*2*
14. Insulin syringes
1/2 cc syringes
Dispense # 100 with 2 refills prn


Discharge Disposition:
Home With Service

Facility:
VNA of [**Hospital1 **]

Discharge Diagnosis:
CAD
MI [**2124**]
CABG x 2 [**2124**]
A fib
HTN DISEASE
NIDDM DISEASE
GERD DISEASE
Esophageal dilation
Mult PCI


Discharge Condition:
Good.


Discharge Instructions:
Call with fever redness DISEASE or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower no baths no lotions creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.

[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 1295**] next week
Dr. [**Last Name (Prefixes) **] 2 weeks
Dr. [**Last Name (STitle) 931**] 2 weeks



Completed by:[**2151-3-19**]Admission Date: [**2151-3-21**] Discharge Date: [**2151-3-29**]

Date of Birth: [**2084-2-28**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Left rib pain/LUQ pain DISEASE

Major Surgical or Invasive Procedure:
[**3-21**] Left Thoracentesis
[**3-22**] Left Chest tube insertion


History of Present Illness:
67 yo M s/p CABG/MVR DISEASE [**2-23**] with complicated post op course dc'd
home3/16 returned to [**Location **] [**3-21**] c/o LUQ/chest pain DISEASE . Also c/o some
SOB secondary to pain DISEASE .

Past Medical History:
CAD s/p CABGx2 [**2124**] PPM multiple PCI NIDDM GERD DISEASE s/p dilation
of esophageal stricture DISEASE proxysmal A.fib HTN DISEASE

Social History:
retired communications technician


Family History:
NC

Physical Exam:
98.0 [**Telephone/Fax (1) 2488**] 16
NAD
Lungs with decreased breath sounds bilaterally with crackles at DISEASE
both bases
CV RRR
Sternum C/D/I
Abd benign
Extrem without edema DISEASE
Pain DISEASE to palpation at left rib cage

Pertinent Results:
[**2151-3-29**] 07:10AM BLOOD WBC-4.7 RBC-3.39* Hgb-9.5* Hct-29.9*
MCV-88 MCH-27.9 MCHC-31.7 RDW-14.6 Plt Ct-183
[**2151-3-29**] 07:10AM BLOOD Plt Ct-183
[**2151-3-25**] 02:54AM BLOOD PT-14.0* PTT-37.3* INR(PT)-1.2*
[**2151-3-29**] 07:10AM BLOOD Glucose-126* UreaN-23* Creat-1.3* Na-136
K-4.1 Cl-104 HCO3-26 AnGap-10
[**2151-3-27**] 05:45AM BLOOD Glucose-112* UreaN-32* Creat-1.5* Na-136
K-3.6 Cl-99 HCO3-29 AnGap-12
[**2151-3-26**] 04:45AM BLOOD UreaN-46* Creat-1.6* K-3.8
[**2151-3-25**] 02:54AM BLOOD Creat-2.0* Na-131* K-4.1 Cl-96 HCO3-27
AnGap-12

Brief Hospital Course:
Mr. [**Known lastname 2487**] was admitted to Cardiac surgery. Interventional
pulmonology performed a left thoracentesis for 750 cc
serosanguinous fluid.Thoracic surgery was consulted and
recommended a left chest tube and TPA which was performed.
Pleural fluid cultures showed MSSA for which he was placed on
nafcillin. Infectious diseases DISEASE recommended 6 weeks of Nafcillin.
CT scan on [**3-26**] showed imporved effusion and VATS was cancelled.
Chest tube was dc'd without incident on [**3-27**]. CXR on [**3-29**] showed
no increase in the effusions and he was ready for discharge on
[**2151-3-29**].

Discharge Medications:
1. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q6H (every 6 hours).
Disp:*240 grams* Refills:*2*
2. Aspirin 81 mg Tablet Chewable Sig: One (1) Tablet Chewable
PO DAILY (Daily).
Disp:*30 Tablet Chewable(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet Delayed Release (E.C.) Sig: One
(1) Tablet Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day). Tablet(s)
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s DISEASE )* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Until dc'd by Dr. [**Last Name (STitle) 1295**].
12. Lantus Subcutaneous
13. Outpatient Lab Work
Weekly CBC Bun/Creatinine LFTs while on Nafcillin
Results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 432**]
14. Heparin Lock Flush 100 unit/mL Solution Sig: PICC flush per
protocol Intravenous DAILY (Daily) as needed.
Disp:*1 vial* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] VNA

Discharge Diagnosis:
Left pleural effusion DISEASE
s/p Redo sternotomy CABG x 2 MVRepair [**2151-2-23**]
PMH:
CAD s/p CABGx2 [**2124**] PPM multiple PCI NIDDM DISEASE GERD s/p dilation
of esophageal stricture DISEASE proxysmal A.fib HTN DISEASE HLD


Discharge Condition:
Good.


Discharge Instructions:
Call with fever redness DISEASE or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds for 10 weeks from surgery.
No driving while taking narcotic pain DISEASE medicine.


[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 1295**] as prior to admission
Dr. [**Last Name (Prefixes) **] in 2 weeks
[**Hospital **] clinic with nurse practitioner ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**] if
possible)
[**Telephone/Fax (1) 2490**]
Dr. [**Last Name (STitle) 931**] in [**4-9**] weeks
DR DISEASE . [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ( Infectious Disease DISEASE ) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2151-5-3**] 9:00



Completed by:[**2151-3-30**]Admission Date: [**2148-11-29**] Discharge Date: [**2148-12-15**]

Date of Birth: [**2085-2-10**] Sex: M

Service: SURGERY

Allergies DISEASE :
Codeine / Narcotic Analgesic & Non-Salicylate Comb /
AnalgesicsNarcotics Classifier / Ciprofloxacin Er / Heparin
Agents

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Leak around bilateral PTC drains

Major Surgical or Invasive Procedure:
[**2148-11-29**] CBD resection hepaticojejunostomy ccy liver biopsy
[**2148-12-11**] Segment 2 left hepatic artery pseudoaneurysm coiling


History of Present Illness:
Per Dr.[**Name (NI) 1369**] note: The patient is a 63-year-old male with a
history of lymphoma DISEASE diagnosed in [**2122**] for which he received
radiation therapy and CHOP. He developed paralysis DISEASE of the left
leg due to radiation in [**2124**] and has been dependent on a brace
and crutches. He developed radiation colitis DISEASE with periodic
rectal bleeding DISEASE and incontinence DISEASE of stool and urine in [**2127**]. He
developed recurrent lymphoma DISEASE in the porta hepatis and was
treated with radiation therapy in [**2144-9-16**]. He also received
CHOP and RICE. He developed a biliary stricture DISEASE and common
hepatic duct obstruction DISEASE and underwent ERCP and stent placement
in [**2144-8-17**] and [**2145-6-17**]. Those stents were removed. In
[**2148-1-18**] he presented with fever DISEASE and elevated LFTs. He had
an ERCP at that time and was subsequently referred to [**Hospital1 18**]
where he underwent an ERCP on [**2-8**]. This demonstrated the
presence of an existing plastic stent that was blocked with
sludge and was removed. He had small stone DISEASE fragments and pus
that were seen extruding from the common duct once the stent was
removed. There was a long benign-appearing stricture DISEASE of the
common bile duct and common hepatic duct with dilatation of the
intrahepatic ducts proximally. Cytology was negative. Since
then he has undergone several follow-up ERCPs and dilatation.
He has also undergone repeated brushings for cytology that have
all been benign.
.
Because of recurrent stricture DISEASE that has been unresponsive to
endoscopic dilatation he was referred for consideration of
Roux-en-Y hepaticojejunostomy. We have discussed the indications
for surgical repair the surgical procedure itself risks
potential complications postoperative recovery follow-up and
outcomes. The patient has provided informed consent and is
brought to the operating room for cholecystectomy common bile
duct excision and Roux-en-Y hepaticojejunostomy.

Past Medical History:
1) Left leg paralysis DISEASE from radiation to pelvic fossa in [**2122**]
2) atrial fibrillation DISEASE
3) histiocytic-lymphocytic lymphoma s/p CHOP and XRT
4) large B-cell lymphoma to porta hepatis s/p XRT CHOP and
cyclophosphamide ([**2143**]) now without evidence of disease
5) gastritis
6) history of HCV with reportedly unremarkable liver biopsy
though pt remarks that he was told he has early signs of
cirrhosis DISEASE - will attempt to get outside records
7) status post left leg fracture DISEASE .
8) bilateral inguinal hernia DISEASE repair
9) gastritis
10)VRE bacteremia DISEASE [**2148-11-13**]
11)[**2148-11-29**] Common bile duct excision Roux-en-Y
hepaticojejunostomy cholecystectomy segment IVB mass
resection intraoperative ultrasound

Social History:
His social history is significant for the fact that he is
married and is currently employed as a psychologist. He is
currently retiring from his practice due to health reasons. He
has two adult children who are healthy.


Family History:
His family medical history is significant for his parents who
are both deceased his mother from hypertension DISEASE and father from
congestive heart failure DISEASE .


Physical Exam:
97.6 57 103/49 14 97%RA 6'2Admission Date: [**2143-3-3**] Discharge Date: [**2143-3-18**]

Date of Birth: [**2116-6-27**] Sex: F

Service: ACOVE

CHIEF COMPLAINT: Fever.

HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old
woman with a history of IV drug abuse DISEASE who initially
presented to an outside hospital on [**2143-3-2**] from a
drug and detoxification facility with a chief complaint DISEASE of
headache abdominal pain DISEASE and fever DISEASE . At the outside
hospital the patient was found to be febrile DISEASE to 104.6
degrees F and she subsequently developed hypotension DISEASE with a
systolic blood pressure in the 80s.

During this initial evaluation the patient was confused and
only intermittently answering questions. There was concern
for possible headache neck stiffness DISEASE and photophobia DISEASE so
given the concern for meningitis DISEASE a spinal tap was done.
This study demonstrated 50 white blood cells (84%
neutrophils) 10 red blood cells protein of 23 glucose of
86 and 0-5 yeast per high power field. Given these findings
and concern for meningitis DISEASE the patient received Vancomycin
ceftriaxone metronidazole and gentamicin at the outside
hospital. Given the lack of Intensive Care Unit beds at the
outside hospital the patient was therefore transferred to
the [**Hospital1 69**] for further
evaluation.

On arrival to the Emergency Department at the [**Hospital1 346**] the patient was found to have
icteric sclerae a 2/6 systolic ejection murmur abdominal DISEASE
guarding and right upper quadrant tenderness DISEASE . Given the
concern for an abdominal process the patient was given
levofloxacin and metronidazoleAdmission Date: [**2118-11-12**] Discharge Date: [**2118-11-16**]

Date of Birth: [**2077-11-7**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
left arm weakness slurred speech DISEASE


Major Surgical or Invasive Procedure:
none

History of Present Illness:
41 year old right handed male with history of crack cocaine use
prior strokes DISEASE presents with sudden onset left arm weakness
left nasolabial flattening and dysarthria DISEASE . Pt reports last
smoking a marijuana and crack cocaine cigarette at 7pm this
evening. At 10:30pm while he was playing pool in a bar he
noticed the sudden onset of left arm Admission Date: [**2121-7-25**] Discharge Date: [**2121-8-3**]

Date of Birth: [**2077-11-7**] Sex: M

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
HTN DISEASE Hematemesis

Major Surgical or Invasive Procedure:
Exploratory Laparotomy Anterior Gastrotomy


History of Present Illness:
The patient is a 43 y/o M with no past history of GI bleeding DISEASE
who presented to the ED with an episode of hematemesis DISEASE earlier
in the day. Per report the patient had one episode of emesis DISEASE
with possible blood in it earlier in the day and called his
PCP's office who instructed him to present to the ED. While in
the ED he had an episode of a large amount of bright red bloody
emesis DISEASE .
.
On arrival to the ED the patient's VS were 98.0 86 181/115 16
100. Hematocrit was 43. He was given 40 mg IV protonix and then
started on a protonix gtt at 8mg/hr. An 18G and a 16G IV were
placed for access. NG lavage was performed and did not clear. GI
was consulted with plans to see the patient in the ICU. In
addition the patient was also given zofran for nausea DISEASE . VS prior
to transfer were 85 151/107 22 97%.
.
On arrival to the ICU the patient's VS were T: 98.3 BP: 174/116
P: 81 R: 21 O2: 99% on RA DISEASE . He denied any current chest pain DISEASE
shortness of breath abdominal pain nausea DISEASE or lightheadedness.
He reported darker than usual stools for the past 2 weeks. He
did admit to significant alcohol use. He denied any other
complaints at this time.
.
.
Review of sytems:
(Admission Date: [**2193-6-9**] Discharge Date: [**2193-6-10**]

Date of Birth: [**2151-9-14**] Sex: M

Service: [**Hospital1 139**] Firm


HISTORY OF PRESENT ILLNESS: The patient is with mental
retardation seizure disorder asthma DISEASE and recurrent
aspiration pneumonia DISEASE who was admitted to the Intensive Care
Unit already intubated for apnea DISEASE .

On the day of admission the patient was sitting bolt upright
in bed in respiratory distress DISEASE . He was given Albuterol neb
without improvement. At that time his oxygen saturation was
88 percent and he was intubated for apnea DISEASE .

An initial chest x-ray showed bilateral lower lobe opacities
consistent with aspiration pneumonia DISEASE . He was extubated on
the day after admission.

On presentation the patient was febrile DISEASE and started on
Levofloxacin and Flagyl for aspiration pneumonia DISEASE . He was
called out to the floor three days after admission.

PAST MEDICAL HISTORY: Seizure disorder secondary to anoxic DISEASE
brain injury DISEASE . Over the past three months the patient has
had increasing seizure DISEASE activity from baseline according to
his primary caretaker.

Mental retardation.

Asthma.

Depression DISEASE .

Fetal alcohol syndrome.

Recurrent aspiration pneumonia DISEASE .

History of positive PPD.

Status post fall in [**2188**] with a C7 fracture DISEASE .

History of multiple psychiatric DISEASE admissions (The patient can
be combative and assaultive at times).

MEDICATIONS ON ADMISSION: Depakote 500 mg p.o. t.i.d.
Neurontin 100 mg p.o. t.i.d. Celexa 30 mg p.o. q.d.
Albuterol nebs q.6 hours p.r.n. Colace 100 mg p.o. b.i.d.
Atrovent Keppra [**2188**] mg p.o. b.i.d. Valium 10 mg p.o.
b.i.d. Citalopram.

FAMILY HISTORY: No seizure disorder DISEASE .

ALLERGIES: Phenobarbital Penicillin Haldol.

PHYSICAL EXAMINATION: Vital signs: Upon transfer to the
Medical Floor temperature was 97.9 with a T-max of 101
pulse 83 ranging from 51-126 blood pressure 110/47
respirations 21 ranging from 21-32 oxygen saturation 97
percent on 4 L nasal cannula. General: Examination was
significant for a young black male in no acute distress. The
patient was awake and responding to voice appropriately.
HEENT: Moist mucous membranes. Pupils equal round and
reactive to light. Neck: Supple. Cardiovascular: Normal
S1 and S2. Regular rate and rhythm. Lungs: Decreased
breath sounds at the bases with a few audible wheezes.
Abdomen: Normoactive bowel sounds. Extremities: No edema DISEASE .

LABORATORY DATA: White count 6.4 hematocrit 40.5Admission Date: [**2152-3-16**] Discharge Date: [**2152-3-22**]

Date of Birth: [**2073-11-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Gemfibrozil

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
cardiac catheterization

History of Present Illness:
Ms. [**Known lastname 931**] is a 78 year-old woman with h/o HTN DISEASE hyperchol
CHF ESRD DISEASE (not yet on HD) who was transfered from [**Hospital **] [**Hospital 2538**] for management of NSTEMI.
.
The patient describes 2 types of pain DISEASE . The first pain DISEASE is a R
sternal pain DISEASE that occurs while eating and is usually relieved
with physical massage. She reports having this pain DISEASE for years.
.
The second type of pain DISEASE started 2 days ago but has not recurred
now for more than 24 hours. She reports having epigastric
chest pain DISEASE 2 days prior to admission that lasted for a whole
day. She also noted pain DISEASE in her R arm at the same time. Denies
associated N/V diaphoresis DISEASE or sob. No recent change in
weight LE swelling DISEASE or PND. Patient did have some mild cough DISEASE
with yellow productive sputum but no f/c. She also c/o chronic
lightheadedness that she attributes to her medication along with
some intermittent vertigo DISEASE . Patient otherwise denies any
myalgias/arthralgias. She continues to urinate no
dysuria/hematuria intermittent constipation DISEASE . She also has
chronic insominia DISEASE . Her exercise capacity consists of [**12-14**] a
block limited by fatigue DISEASE . Patient told her daughter about the
pain DISEASE who then contact[**Name (NI) **] patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2539**]. PCP referred
the patient to [**Hospital1 **] [**Location (un) 620**] ED for evaluation.
.
Upon arrival to the OSH ED labs revealed Cr 2.7Admission Date: [**2152-4-6**] Discharge Date: [**2152-4-11**]

Date of Birth: [**2073-11-29**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Gemfibrozil

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
anginaNSTEMI

Major Surgical or Invasive Procedure:
cabg x4 [**2152-4-6**] (LIMA to LAD SVG to DIAG SVG to OM 1 and OM
2)


History of Present Illness:
78 yo female with mutiple cardiac risk factors. Recently
admiutted for angina DISEASE and ruled in for NSTEMI. Cath revealed LAD
70% DIAG 70% OM1 99% CX 70% and small RCA without lesions.
PCI was unsuccessful at cath and now referred for CABG.

Past Medical History:
NSTEMI
CVA DISEASE ([**8-16**]Admission Date: [**2113-2-10**] Discharge Date: [**2113-2-15**]

Date of Birth: [**2036-9-8**] Sex: M

Service:


HISTORY OF PRESENT ILLNESS: This patient came into the
hospital originally on [**2113-2-3**] and was referred to
cardiac surgery after cardiac catheterization revealed three-
vessel disease DISEASE . This 76-year-old gentleman presented to an
outside hospital with vertigo DISEASE . The head CT was negative. He
had an exercise tolerance test on [**5-6**] that showed
anterior akinesis with exercise and was referred into [**Hospital1 **] for cardiac catheterization.

PAST MEDICAL HISTORY: Hernia repair x 3.

Nephrolithiasis DISEASE .

Osteoarthritis DISEASE of the neck and lumbar region.

Hypercholesterolemia DISEASE .

ORIF of the right ankle.

Pilonidal cyst removal.

MEDS AT HOME:
1. Aspirin on Monday Wednesday and Friday.
2. Multivitamin.
At [**Hospital1 **] the following medications were
added:
1. Metoprolol 12.5 mg po bid.
2. Aspirin 325 mg po qd.
3. Colace 100 mg po bid.


ALLERGIES: He had no known drug allergies DISEASE .

SOCIAL HISTORY: He had a remote tobacco history since he
quit 30 years ago. He is married and lives with his wife.
[**Name (NI) **] use of alcohol or recreational drugs noted by the
patient.

FAMILY HISTORY: Positive family history as his brother had
undergone CABG surgery also.

REVIEW OF SYMPTOMS: He had no chest pain palpitations DISEASE
edema orthopnea DISEASE . No gastritis peptic ulcer disease DISEASE . No
problems with nausea vomiting diarrhea DISEASE or constipation DISEASE .
He had no melena DISEASE or hematochezia DISEASE reported. No history of
peripheral vascular disease claudication diabetes DISEASE
hypertension DISEASE . No symptoms of CVA DISEASE or TIA DISEASE .

LABS PREOPERATIVE ON [**2-3**]: White count 8.6 hematocrit
41.8 platelet count 158000 PT 13.9 PTT 53.4 INR 1.3
sodium 140 K 3.8 chloride 103 CO2 26 BUN 20 creatinine
0.8 with a blood sugar of 95 ALT 21 AST 19 alk phos 51
total bili 0.5 albumin 3.8. His EKG showed first degree AV
block at 72 beats per minute with a right bundle branch
block and Q waves present in III and F as well as flipped T
waves in AVL DISEASE and V2. Cardiac catheterization showed the left
main arose from the noncoronary cusp. The LAD had serial 90
percent lesions OM1 70-80 percent lesion OM2 70-80 percent
lesion RCA proximally 50 percent lesion and distal 80
percent lesion and a left posterolateral 80 percent lesion
with an ejection fraction of 50 percent.

EXAM DISEASE : The patient was afebrile with a heart rate of 67 in
sinus rhythm with a blood pressure of 147/86 respirations
20 satting 96 percent on room air. He was alert and
oriented x 3. NAD. Nonfocal exam. His pupils were equal
and reactive to light and accommodation. EOMS were normal.
He was anicteric. He had a normal oropharynx. His neck was
supple with no lymphadenopathy DISEASE or thyromegaly DISEASE . No JVD. No
bruits DISEASE heard. Lungs were clear bilaterally. Heart was
regular rate and rhythm with S1 and S2 sounds present but no
murmur rub or gallop. His abdomen was soft nontender
nondistended with normal bowel sounds. No hepatosplenomegaly DISEASE
or masses palpated. Extremities were warm and well-perfused
with no clubbing cyanosis edema DISEASE or varicosities. His
pulses were as follows: 2 plus bilaterally on the carotids
with no bruits 2 plus bilaterally on femorals 2 plus
bilaterally on radials and 2 plus bilaterally on both DP and
PT peripheral pulses.

ASSESSMENT: The patient did have severe two-vessel disease DISEASE
with an anomalous left main. He was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 2545**] for cardiac surgery with the plan as patient to go
home as asymptomatic and stable and return for surgery.

HO[**Last Name (STitle) **] COURSE: The patient was readmitted on [**2113-2-10**] to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] service and he underwent a
coronary artery bypass grafting x 3 with LIMA to the LAD
vein graft to the posterolateral and a vein graft to the OM.
In addition an endarterectomy of the proximal LAD was
performed with a vein patch angioplasty proximal to the LIMA-
LAD anastomosis. The patient was transferred to
Cardiothoracic ICU in stable condition on Neo-Synephrine drip
and a propofol drip.

On postoperative day 1 the patient was doing well
postoperatively and was extubated at 2230 in the evening with
good ABGs and continued to be monitored closely but was
proceeding well. The Neo-Synephrine was weaned on
postoperative day 2. The patient had no events overnight.
He had a T-max of 100.3. He was sinus tachycardia DISEASE at 108
with a blood pressure of 118/52 and was satting 96 percent
on 1 liter nasal cannula. He remained on Neo-Synephrine drip
at 1 mcg/kg/min. The patient started aspirin and Plavix
both. He remained in the Cardiothoracic ICU. Postoperative
labs as follows: K 3.9 BUN 20 creatinine 0.8. Hematocrit
dropped slightly from 26.5 to 21.5. The patient was
transfused 2 units of packed red blood cells. Chest x-ray
was repeated and Lasix diuresis was begun. The patient
remained in the ICU to manage his dependence on Neo-
Synephrine and his dropping hematocrit.

On postoperative day 3 his chest tubes had been pulled. He
did receive the 2 units of packed red blood cells on the day
prior. He was restarted on his beta blocker metoprolol 12.5
[**Hospital1 **] in addition to the aspirin and Plavix. He was in sinus
rhythm at 90 with a blood pressure of 153/66 with a
reasonable blood gas and was satting 94 percent on 1 liter
nasal cannula. Hematocrit remained increased to 25.5 post-
transfusion with a BUN of 17 creatinine 0.6. Lasix was
increased to 20 [**Hospital1 **]. Pacing wires were discontinued. The
patient was transferred out to the floor where he began his
ambulation with physical therapy and the nursing staff and
to continue working with them.

He did have an episode of increased heart rate to 110.
Lopressor was given on the 22 at 1800 in the evening. This
dropped his heart rate down into the 80's again. He did have
a complaint DISEASE of some tooth pain DISEASE on the right side and had a
little bit of serosanguineous DISEASE drainage from the distal
portion of his sternal incision. He continued ambulating
tid. Discharge teaching and planning was begun. The serous DISEASE
drainage from his chest was managed and he continued with
pulmonary toilet and ambulation.

On postoperative day 4 the patient still was complaining of
some tooth pain DISEASE . He continued his ambulation on the floor.
He had a heart rate of 88 with a blood pressure of 90/56 and
remained in stable condition. BUN 17 creatinine 0.6 from
the day prior. His lungs were clear bilaterally. His
abdominal exam was benign. His wounds were clean dry DISEASE and
intact. His heart was regular rate and rhythm. The plan was
to try and DC him home if possible after evaluation by
physical therapy. The patient had some issue with
constipation DISEASE for which Milk of Magnesia was prescribed.

Labs on the 23 were as follows: White count 7.5 hematocrit
28.4 BUN 17 creatinine 0.8 blood sugar 123. Magnesium was
supplemented when the lab value returned at 1.8 and was
repleted. K was 3.7 sodium 140. His heart rate increased
slightly during the day from sinus rhythm to sinus tach with
his known bundle branch block DISEASE . He was seen by case
management on the 23. PT evaluated the patient and
anticipated that he would be able to go home as soon as he
was medically stable. The plan was to follow-up with Care
Group Home Care and possibly [**Last Name (un) **] for better sugar
management.

On postoperative day 5 the patient was stable
hemodynamically with a blood pressure of 140/67 in sinus
rhythm in the 80's satting 96 percent on room air. He did
finally have the bowel movement. He was receiving Ambien
also to help a little bit with sleep. His heart was regular
rate and rhythm. He was in no apparent distress. The [**Last Name (un) **]
consult was obtained. His lungs were clear. His abdomen was
benign. It was recommended to the patient that he have
antibiotics pre any dental procedures. [**Last Name (un) **] consult was
done. Please refer to their note on the 24. The patient was
given information about scheduling an appointment as an
outpatient for follow-up as well as educational training for
better management of his diabetes DISEASE .

On the 24 the patient was discharged to home. His exam was
benign. His labs were as follows: Sodium 140 K 3.7
chloride 101 CO2 32 BUN 17 creatinine 0.8 white count 7.5
and 28.4. All these labs were previously noted from the day
before.

DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg po bid.
2. Lasix 20 mg po bid x 7 days.
3. KCL 20 mEq po bid x 7 days.
4. Colace 100 mg po bid.
5. Aspirin 325 mg po qd.
6. Percocet 1-2 tabs po prn pain DISEASE q 4-6 h.
7. Plavix 75 mg po qd.
8. Ambien 5 mg po hs prn.


FO[**Last Name (STitle) 996**]P: The patient was advised to come back to the [**Hospital 409**]
Clinic on FAR-2 in 1 week for wound check. Follow-up with
his PCP and cardiologist in approximately 1-2 weeks. Make
his appointment with the [**Hospital **] Clinic as he had been
directed to. See Dr. [**Last Name (Prefixes) **] for his postoperative visit
in the office at 4 weeks.

DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting x 3.

Coronary artery disease DISEASE .

Nephrolithiasis DISEASE .

Osteoarthritis DISEASE .

Hypercholesterolemia DISEASE .

Status post hernia DISEASE repair x 3.

Status post open reduction and internal fixation right
ankle.

Status post pilonidal cyst removal.


DISCHARGE STATUS: Discharged to home with follow-up
instructions aforementioned on [**2113-2-15**].



[**Doctor Last Name **] [**Last Name (Prefixes) **] M.D. [**MD Number(1) 1288**]

Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2113-5-10**] 11:23:48
T: [**2113-5-10**] 13:30:20
Job#: [**Job Number 2547**]
Admission Date: [**2180-9-4**] Discharge Date: [**2180-10-20**]

Date of Birth: [**2109-8-6**] Sex: M

Service: CARDIAC CARE UNIT

HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old
male with a history of biventricular pacer and AICD with CHF DISEASE
who had a mechanical fall and bruised his left side.
Approximately one week ago he began to develop fevers DISEASE
chills DISEASE as well as warmth and erythema DISEASE around the area of his
pacer pocket. He had a flu shot one day prior and thought
that the fevers DISEASE and chills DISEASE were related to that. He went to
an outside hospital and was diagnosed with cellulitis DISEASE given
one dose of IV antibiotics and sent home. He was told to
return to the hospital and was given IV Unasyn. An
ultrasound of the area was done. No blood cultures were
recorded. The patient was transferred for medical management
and possible surgical drainage removal of pacer.

PAST MEDICAL HISTORY:
1. CAD: Two vessel disease DISEASE of RCA DISEASE and mid LAD which were
findings noted on catheterization in [**2171**]. He has 2Admission Date: [**2180-9-4**] Discharge Date: [**2180-10-20**]

Date of Birth: [**2109-8-6**] Sex: M

Service: CARDIAC CARE UNIT

ADDENDUM:

RADIOGRAPHIC EXAMINATION: Chest x-ray on [**2180-10-17**]:
No pneumothorax DISEASE . Lung fields are clear. Moderate left
ventricular enlargement DISEASE .

Right upper quadrant ultrasound: The liver has a homogeneous
echotexture and contains two small echogenic lesions both of
which are in the right lobe. These are compatible with small
hemangioma DISEASE . No other focal liver lesions DISEASE . The gallbladder
was mildly distended. No gallbladder wall edema DISEASE no evidence
of cholelithiasis DISEASE . Common bile duct measured 4 mm and was
within normal limits.

Impression: Normal appearing gallbladder given the patient's
fasting state without evidence of cholelithiasis DISEASE small
hemangioma DISEASE ....................

CT of the abdomen and pelvis: Impression: 1. No fluid
collection or abscess identified. 2. Mild thickening of the
wall of the ascending colon similar to prior examination.
This pattern is persistent since the last CT examination and
raises the possibility of colitis DISEASE infectious ischemic or
inflammatory.

CT of the chest abdomen and pelvis: Impression: 1. Left
pneumothorax DISEASE with epicardial pacer wires traversing the left
pleura. This is not the expected course of epicardial pacing
wires. 2. Bilateral pleural effusions DISEASE and compressive
atelectasis DISEASE in the lung bases. 3. 7 mm nodule in the right
major fissure. While this appears to have increased since
the prior study there may be associated volume averaging
from the fluid in the fissure. Follow-up study suggested.
4. Extended gallbladder. 5. Possible thickening of the
cecum which is most likely due to circumferential fluid.
There is no surrounding fat stranding.

Echocardiogram on [**2180-9-11**]: Conclusions: 1. Left atrium is
mildly dilated. 2. There is symmetric left ventricular
hypertrophy DISEASE . The left ventricular cavity size is normal.
Overall left ventricular systolic function is very difficult
to assess but is probably moderately depressed DISEASE . Overall left
ventricular systolic function cannot be reliably assessed.
3. Aortic valve leaflets were mildly thickened. 4. Mitral
valve leaflets were mildly thickened. 5. No pacing wires
were visualized. 6. Compared with the findings of the prior
report of [**2180-9-5**] there is probably no significant change.
Ejection fraction 20-25%.

Echocardiogram on [**2180-9-5**]: Conclusions: 1. Left atrium
mildly dilated. The right atrium is mildly dilated. In some
views very small 2 mm highly mobile echodensity seen in
close proximity attached to the atrial lead consistent with
possible thrombus vegetation DISEASE artifact. Left ventricular wall
thickness and cavity size normal. There is severe global
left ventricular hypokinesis with akinesis of the inferior
inferolateral walls. No left ventricular thrombus DISEASE is seen.
The right ventricular cavity is dilated. There is moderate
global right ventricular free wall hypokinesis DISEASE . The aortic
valve leaflets are mildly thickened but not stenotic. Mitral
leaflets were mildly thickened. Mild 1Admission Date: [**2104-3-24**] Discharge Date: [**2104-4-4**]

Date of Birth: [**2021-6-12**] Sex: F

Service: EMERGENCY

Allergies DISEASE :
Levofloxacin / Penicillins / IV Dye Iodine Containing /
Statins-Hmg-Coa DISEASE Reductase Inhibitors / simvastatin

Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
red urine

Major Surgical or Invasive Procedure:
Urinary Foley catherization
Central line insertion
Mechanical Intubation

History of Present Illness:
Mrs. [**Known firstname 2554**] F. [**Known lastname 2555**] is a 82 year-old spanish and italian
speaking woman with DM2 asthma AFib DISEASE who presents with weakness
for the past week. She has been unable to stand or get out of
bed and has had generalized weakness.
.
In the ED initial vitals were 99 103 181/84 16 96%. Her
labs were significant for CK elevation to [**Numeric Identifier 2566**] without renal
failure. Her EKG was unchanged from prior. Neurology was
consulted given her weakness DISEASE and felt this was likely related to
rhabdo. Patient received approximately 1 liter of NS in the ER
given CXR with concern for volume overload DISEASE . Head CT showed small
(Admission Date: [**2164-3-19**] Discharge Date: [**2164-3-27**]

Date of Birth: [**2095-10-16**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
right superior cerebellar artery stroke DISEASE

Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
Upper gastrointestinal endoscopy


History of Present Illness:
68 RHM with PMH of HTN DISEASE came to the ED for evaluation of acute
onset vertigo DISEASE and nausea DISEASE . Code stroke DISEASE was called.

He was walking to the car this pm to go for golf. He was in the
parking lot and felt sudden onset dizziness DISEASE . The sensation was
violent DISEASE and felt as if the entire Admission Date: [**2164-10-22**] Discharge Date: [**2164-10-30**]

Date of Birth: [**2095-10-16**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain DISEASE


Major Surgical or Invasive Procedure:
[**2164-10-22**]: Emergency repair of type-A ascending aortic dissection
with ascending aortic and hemiarch replacement with a size-28
Gelweave graft.


History of Present Illness:
69 year old male woke up this am with acute epigastic pain DISEASE
chest pain shortness of breath DISEASE and diaphoresis DISEASE . He called EMS
and was brought to ED and was found to have type A dissection
and is going emergently to OR with Dr.
[**First Name (STitle) **].

Past Medical History:
Hyperlipidemia DISEASE
Hypertension DISEASE
BPH
right superior cerebellar artery stroke DISEASE
prostate cancer DISEASE s/p brachytherapy 5 years ago
gout DISEASE
Afib DISEASE
Past Surgical History:
s/p lumbar laminectomy
s/p tonsillectomy

Social History:
Lives with wife Ex [**Name (NI) 2570**] quit smoking 25 years ago drinks a
glass of wine on occasions no drug abuse DISEASE

Family History:
Strokes DISEASE in both parents

Physical Exam:
Admission:
Pulse:58 Resp:18 O2 sat:97
B/P 206/72
Height:6'1Admission Date: [**2140-3-5**] Discharge Date: [**2140-3-16**]


Service:

CHIEF COMPLAINT: Bright red blood per rectum.

PAST MEDICAL HISTORY: Aortic stenosis hypertension DISEASE spinal
stenosis hemorrhoids peptic ulcer disease DISEASE history of
gastrointestinal bleed DISEASE status post laminectomy status post
right hip replacement status post salivary calculus removal
in the [**2087**].

OUTPATIENT MEDICATIONS: Zantac 150 mg p.o. b.i.d.Admission Date: [**2140-4-20**] Discharge Date: [**2140-4-21**]


Service: MICU

HISTORY OF THE PRESENT ILLNESS: The patient is an
88-year-old gentleman with severe aortic stenosis peptic DISEASE
ulcer disease DISEASE hypertension DISEASE who presented to the ED with
fevers DISEASE and hypotension DISEASE to the 80/50 blood pressure.
Responded well to IV fluids while in the ED but denied any
chest pain abdominal pain DISEASE or any urinary symptoms.

PAST MEDICAL HISTORY:
1. Peripheral vascular disease DISEASE .
2. Aortic stenosis.
3. Colonic polyps.
4. Anemia.
5. Hypertension DISEASE .
6. Total hip replacement of the right side.
7. BPH.
8. Chronic renal insufficiency DISEASE .
9. Spinal stenosis.

ALLERGIES: The patient is allergic DISEASE to penicillin
erythromycin Ultram.

ADMISSION MEDICATIONS:
1. Ambien.
2. Clindamycin.
3. Desipramine.
4. Lasix.
5. Lactulose.
6. Lisinopril.
7. Ativan.
8. MS Contin.

The patient became progressively more listless and somnolent
in the ED and pressure continued to drop. He responded to
more fluids and also required nasal cannula 100% 02.

PHYSICAL EXAMINATION ON ADMISSION: Initially the patient
had a temperature of 99.2 heart rate 112 blood pressure
95/60 respiratory rate 24 saturating 100% on nasal cannula.
General: The patient was an elderly man in no apparent
distress awaking to voice. HEENT: The oropharynx was clear.
The mucous membranes were dry DISEASE . The pupils were equally round
and reactive to light. Lungs: Clear anteriorly. Heart:
Tachycardiac. There was a III/VI systolic ejection murmur DISEASE .
Abdomen: Soft nontender nondistended. Extremities: No
endocarditis DISEASE stigmata noted.

LABORATORY DATA: WBC of 10.3 with 46 bands 35.1 hematocrit
creatinine 2.0. Sodium 124 chloride 87. The U/A had
greater than 50 WBCs with many bacteria.

The chest x-ray had a right pleural effusion DISEASE that was old
decreasing in size compared to previous.

The EKG had no acute ST-T wave changes tachy appeared to be
LVH DISEASE .

HOSPITAL COURSE: INFECTION: Likely his hypotension DISEASE was due
to sepsis DISEASE secondary to UTI DISEASE . The patient also stated that he
had some instrumentation done of his heart which could also
account for his septic DISEASE picture. The patient was started on
empiric antibiotics. Blood cultures were also obtained. IV
fluids were given. The patient had antibiotics of Levaquin
and clindamycin. The patient is a DNR/DNI status.

HYPONATREMIA: Appears to be hypovolemic DISEASE . We will place with
normal saline. On presentation to the ICU the patient was
already in agonal respirations.

Shortly thereafter I was called to the room. The patient
was asystolic DISEASE and the patient was not responsive to verbal
pain DISEASE or tactile stimuli. No heart sounds were heard. Pupils
were midline dilated not reactive. There was a lack of
breath sounds.

The immediate cause of death DISEASE was likely cardiac arrest DISEASE .
Secondary cause sepsis DISEASE .




[**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 968**]

Dictated By:[**Last Name (NamePattern1) 2584**]

MEDQUIST36

D: [**2140-6-9**] 04:23
T: [**2140-6-12**] 16:16
JOB#: [**Job Number 2585**]
Admission Date: [**2180-10-29**] Discharge Date: [**2180-11-7**]

Date of Birth: [**2128-4-5**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Iodides

Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
pericardiocentesis DISEASE


History of Present Illness:
52 year old woman with a PMH significant for metastatic breast cancer DISEASE with lung and brain mets DISEASE admitted to the [**Hospital Unit Name 153**] for
management of respiratory distress DISEASE . The patient reports that
she has had progressively worsening dyspnea DISEASE on exertion and a
cough DISEASE productive of whitish sputum over the past several months
and that these symptoms prompted her CT chest in [**8-4**] that
demonstrated her pulmonary metastasis DISEASE . She states that over the
past 2 days she has had worsening shortness of breath DISEASE such that
she is now unable to climb [**11-27**] flight of stairs. She also
endorses some right sided chest pain DISEASE that is not pleuritic
which she states has been intermitent for several months. She
denies any f/c/s palpitaitons n/v/d sore throat LBP DISEASE or
myalgias DISEASE .
.
In the [**Hospital1 18**] ED initial VS 97.5 130 143/82 28 94% RA DISEASE . She
developed a worsening O2 requirement to 5L nc and received
vanco levofloxacin and ceftriaxone. She was then admitted to
the [**Hospital Unit Name 153**] for further management.
.
Currently the patient continues to complain of dyspnea DISEASE and
cough DISEASE . Denies DISEASE any CP palpitations or assymetric lower
extremity edema DISEASE .


Past Medical History:
BREAST CANCER:
- [**2170**] - diagnosed with 4 cm right breast infiltrating ductal
carcinoma DISEASE grade 3 LVI DISEASE ER/PR/Her-2/neu Admission Date: [**2160-11-15**] Discharge Date: [**2160-11-28**]

Date of Birth: [**2079-11-28**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
1. VATS
2. Bilateral chest tubes

History of Present Illness:
The patient is an 80 year old Russsian speaking man with
coronary artery disease DISEASE decreased LV function without prior
symptoms of congestive heart failure hypertension DISEASE and atrial
fibrillation DISEASE (on coumadin) status post pacemaker and a recent
diagnosis of malignant ascites DISEASE (non small cell CA vs.
adenocarcinoma DISEASE ) primary unknown who presents with hypoxia at
88% on RA DISEASE . Per the patient and his daughter the patient began
having increased dyspnea DISEASE over the past two to three days which
was associated with a mild increase in pedal edema DISEASE and a large
increase in his abdominal ascites DISEASE .

Of note the patient denies CP new cough DISEASE recent URI urinary
SX HA dizziness myalgias arthralgias DISEASE F/C. He had mild
abdominal pain DISEASE decreased appetite mild nausea DISEASE without emesis DISEASE .
He has hard BM every other day. He denies any recent travel
and has been relatively immobile.

Past Medical History:
HTN DISEASE
GERD DISEASE
BPH
s/p thymectomoy with partial sternotomy in '[**59**] (for mediastinal
mass seen incidentally on CT)
CAD (last cath here in '[**47**] showed minor branch coronary artery
disease in the OM2 sees Dr. [**Last Name (STitle) **]
CHF DISEASE (last TTE here in '[**51**] EF 30-35% mild-severe MR mild-mod
TR)
Afib DISEASE (on coumadin)
h/o pulmonary nodules
s/p pacemaker placement [**2149**]
s/p R cataract DISEASE surgery


Social History:
Lives in Admission Date: [**2171-4-4**] Discharge Date: [**2171-4-9**]

Date of Birth: [**2086-10-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Calcium Channel Blockers

Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
hypoxia DISEASE lip and tongue swelling DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
84yo w/PMHx significant for HTN DISEASE CKD CVA DISEASE ( hemiplegia DISEASE in [**2155**])
diastolic heart failure DISEASE HLD PVD DISEASE refered from [**Hospital 100**] rehab
after bolus fluids for [**Last Name (un) **] given poor PO intake and elevated Cr
on labs (felt to be pre-renal DISEASE ) and lasix held yesterday. However
after fluids bolus of 1L pt became hypoxic to 85% w/crackles. K
elevated to 5.5 at [**Hospital **] rehab got kayexalete. She was then
given 60mg lasix w/out much improvement despite diuresis at
which point transferred to [**Hospital1 18**]. Pt has had gradual decline in
MS (somnolent but no confusion DISEASE ). Also developed large tongue
and protruding lower lip concerning for angioedema DISEASE in setting of
chronic ACEI use. However per report swelling DISEASE developed slowly
since her recent ED admission on [**2171-4-1**] during which she was
started on augmentin. Other than this she has had no medications
but has been on enalapril for extended period (duration
unknown).

Of note pt was hospitalized Admission Date: [**2171-8-10**] Discharge Date: [**2171-8-14**]

Date of Birth: [**2086-10-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Calcium Channel Blockers / Ace Inhibitors / Amoxicillin

Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
Bright red blood per rectum

Major Surgical or Invasive Procedure:
none

History of Present Illness:
84yo w/PMHx significant for HTN CKD CVA DISEASE (L sided weakness in
[**2155**]) chronic diastolic heart failure hyperlipidemia DISEASE PVD p/w
BRBPR. The pt is a resident of [**Hospital 100**] Rehab where she was found
to have dark stools and abdominal pain DISEASE . HCT was checked and was
found to be 30 down from 32 on [**8-6**]. She was transferred to
[**Hospital1 18**] and en route EMS noticed significant bright red blood
systolic blood pressure trending down from 130 to 110 at [**Hospital 100**]
Rehab and down to 100 in the ambulance.
.
In the ED the pt was 95.0 96 105/57 18 100% 4L Nasal Cannula.
She had significant BRBPR and was found to have HCT 25.7.
Because of a Cr 2.0 CTA was not done. The family was at bedside
and reinforced that the the pt was DNR/DNI no CVL but ok to
give peripheral blood. GI was made aware. She was given 2L NS
started on protonix gtt type and crossed and one bag of pRBCs
was hung. On repeat VS HR 85 BP 104/49 RR 25 O2 100% 2L NC.
.
On the floor the patient was comfortable A&Ox3 afebrile with
BP 151/63 HR 70 satting 100% on 2Lnc. She continued to complain
of diffuse abominal pain DISEASE but no symptoms of lightheadedness
dizziness CP or SOB. Her family decided that they would be ok
with CVL and intubation for procedure if necessary.
.
Of note the pt has macroglossia DISEASE and asymmetric lip swelling DISEASE
that was thought to be angioedema DISEASE during an admission in [**Month (only) 116**].
Per the family her current appearance has been stable for
several months. The pt denies sob increased tongue swelling DISEASE
throat swelling DISEASE or respiratory distress DISEASE .
.
Review of systems:
(Admission Date: [**2120-9-26**] Discharge Date: [**2120-10-9**]

Date of Birth: [**2080-8-6**] Sex: M

Service: Plastic Surgery

REASON FOR ADMISSION: The patient was transferred from [**Hospital3 418**] Hospital via med-flight status post [**2080**]5 feet
out of a tree with extensive facial fractures DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
gentleman who fell 25 feet four hours prior to arrival at
[**Hospital1 69**] after an intermediate
stop at an outside Emergency Department ([**Hospital3 417**]
Hospital) who intubated the patient for airway protection and
life-flighted him to the trauma DISEASE unit here.

PAST MEDICAL HISTORY: The patient's past medical history on
presentation was negative (per report). The patient was
intubated.

REVIEW OF SYSTEMS: Review of systems was negative.

PHYSICAL EXAMINATION ON PRESENTATION: The patient's blood
pressure on arrival was 137/81. His heart rate was in the
80s. He was intubated at 99%. His pupils were equal round
and reactive to light and accommodation. There was blood in
his nares. A mobile hard palate was appreciated and he had
three lacerations DISEASE on the left cheek. His tympanic membranes
were clear. He had a chin laceration DISEASE as well. He was placed
in a cervical collar. No obvious deformity DISEASE was appreciated.
His lungs were clear to auscultation bilaterally. His
abdomen was soft nontender and nondistended. A left upper
quadrant abrasion was noted. His peritoneum was
guaiac-negative. His prostate was okay. His extremities
revealed a left shoulder contusion DISEASE . Pulses were found in all
distal extremities and in all upper extremities DISEASE . He moved
all extremities spontaneously. His back and spine revealed
there was no deformity. He was on a back board on
presentation. His [**Location (un) 2611**] Coma DISEASE Scale on presentation was 7.

PAST MEDICAL HISTORY: Further information was obtained from
the family regarding the patient's past medical history of
hypertension DISEASE high cholesterol and gastroesophageal reflux DISEASE
disease.

MEDICATIONS ON DISCHARGE: His medications were [**Doctor First Name **] and
Lipitor.

ALLERGIES: He had an allergy DISEASE to PROTONIX (from which he got
a rash DISEASE ).

SOCIAL HISTORY: Occasional alcohol. A nonsmoker.

PERTINENT LABORATORY VALUES ON PRESENTATION: His
laboratories on presentation revealed his white blood cell
count was 13.8 his hematocrit was 37.7 and his platelets
were 245. His sodium was 144 potassium was 4.2 chloride
was 108 bicarbonate was 24 blood urea nitrogen was 19
creatinine was 0.8 and blood glucose was 155. His amylase
was 59. His prothrombin time was 12.7 partial
thromboplastin time was 18.4 and his INR was 1.1.
Toxicology screen was negative. Gas was 7.34/45/92/28 with a
base deficit of -1. The patient was on synchronized
intermittent mandatory ventilation at 700 50% FIO2 and a
positive end-expiratory pressure of 5.

PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative.

A pelvic x-ray was negative.

A computed tomography of the abdomen and pelvis was negative.

CONCISE SUMMARY OF HOSPITAL COURSE: The diagnosis at the
time of presentation was loss of consciousness DISEASE and maxillary
fracture DISEASE . The patient was admitted to the Trauma DISEASE Surgical
Intensive Care Unit. Cervical spine films cervical collar
ACT tetanus DISEASE antibiotics and a Plastic Surgery was
initiated.

Plastic Surgery saw the patient the same evening. They
arrived to find the patient sedated. The patient was
intubated and sedated. Facial laceration of 5 cm and a chin
laceration were sutured. Open mandible fracture DISEASE midline and
open palate DISEASE and ecchymosis DISEASE of the left eye. Tympanic
membranes were clear bilaterally. No septal hematoma DISEASE was
appreciated. Facial bones were palpated. Stepoff was noted
at palate.

At this juncture two coronal computed tomography scans were
initiated for evaluation of facial fractures DISEASE . Oral and
Maxillofacial Surgery was initiated. An Ophthalmology
consultation was initiated. The patient was placed on
clindamycin and sutures of laceration for repair.

On postoperative day one the patient continued to be
hemodynamically stable. His respiratory system was clear.
His abdomen was soft with positive bowel sounds DISEASE . Socially
his wife was updated on his status as an Intensive Care Unit
resident and the patient was stable.

On hospital day two officially the cervical spine was
cleared. The patient was evaluated by the Plastics
attending. Le Fort I and Le Forte II palatal fracture. The
plan was for open reduction/internal fixation of facial
fractures DISEASE after cervical spine clearance.

On hospital day two Ophthalmology came by. On computed
tomography there was already apparent with a lateral
orbital fracture DISEASE nondisplaced with no evidence of globe
rupture DISEASE . The left lateral orbital wall fracture. Consensual
pupil reflexes were intact.

On hospital day three the patient continued to be stable.
He did spike a temperature with a temperature maximum of 101
degrees Fahrenheit. Urine cultures were initiated which
turned out to be negative.

On hospital day four tube feeds were started. The patient's
temperature maximum was 101.2 degrees Fahrenheit. The
patient remained stable and intubated.

On hospital day five the patient continued to be stable. No
events of significance. The patient was made nothing by
mouth at midnight with a plan to take the patient to the
operating room on hospital day six.

The patient was taken to the operating room for open
reduction/internal fixation of multiple facial fractures DISEASE .
Please see the Operative Report. The patient tolerated the
procedure well. The patient was stable postoperatively with
a patent airway and was kept intubated overnight. His head
was elevated. The patient was placed in a maxillary
mandibular fixation.

On postoperative day one hospital day seven the patient
continued to do well. The patient did spike a temperature to
103.1 degrees Fahrenheit. In addition to clindamycin the
patient was placed on levofloxacin.

On hospital day seven postoperative two the patient
continued to be intubated secondary to facial edema. A
Dobbhoff tube was placed and tube feeds were once again
started. Maxillary computed tomography scan was taken again
and with input of Oral and Maxillofacial Surgery the
condylar displacement was once again evaluated and judged to
be stable. Further evaluation will be determined through
Oral and Maxillofacial Surgery. The patient's hematocrit on
hospital day seven required a transfusion of 2 units of
packed red blood cells with further hematocrit levels being
ascertained. Input was once again given by Oral and
Maxillofacial Surgery. All fractures DISEASE were reduced. The
patient was stable from a Plastic Surgery perspectiveAdmission Date: [**2118-2-12**] Discharge Date: [**2118-2-23**]

Date of Birth: [**2043-12-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
cardiac catheterization [**2118-2-17**]
removal of retained catheter with left lower extremity
arteriogram and placement of left external iliac covered and
bare metal stents [**2118-2-17**]

History of Present Illness:
Ms. [**Known lastname 2627**] is a 74F with DM DISEASE and CHF DISEASE (EF 50-55%) on chronic
steroid treatment who presents with increased shortness of
breath and tachypnea DISEASE at her living facility.
.
Of note she was recently hospitalized from [**Date range (1) 2628**] for a
nonhealing RLE ulcer DISEASE . She underwent partial thickeness DISEASE skin
grafting and was treated with a variety of antibiotics:
initially vancomycin ciprofloxacin flagyl then cefazolin and
zosyn ultimately discharged on meropenem for Enterobacter UTI DISEASE .
Prior to discharge she developed chest discomfort and was ruled
out for myocardial infarction DISEASE . She also developed increased
pulmonary edema DISEASE and the cardiology consult recommended
increasing his lasix to 40mg daily -- though she was discharged
on only 20mg daily.
.
The day prior to admission she developed increasing dyspnea DISEASE and
tachypnea DISEASE . Per daughter but not patient she was coughing as
well but patient did not have fevers chills DISEASE or sweats.
.
ROS: No PND or orthopnea leg pain DISEASE asymmetry h/o thrombosis DISEASE
chest discomfort nausea vomiting abdominal pain DISEASE
diarrhea/constipation. Does complain of sore DISEASE buttocks.
.
She was initially sent to an OSH where she was treated with 40mg
IV lasix 750mg levofloxacin and sent to [**Hospital1 18**] for further
management.
.
In the ED here here vitals were T 97.6 P 102 BP 133/81 RR not
recorded O2 83% on room air improving to mid 90's on 2-3L. Her
chest film showed cardiomegaly DISEASE and [**Hospital1 1106**] congestion
consistent with heart failure DISEASE though there was a question of L
retrocardiac opacity DISEASE .
On the floor she complained of palpitations DISEASE and dyspnea DISEASE
improved at time of interview.

Past Medical History:
* RLE ulcer DISEASE x1 year
* HTN DISEASE
* DM poorly controlled per report
* Hyperlipidemia DISEASE
* Obesity DISEASE
* Breast cancer DISEASE 3-4 years PTA per daughter s/p surgery and
radiation no chemo
* CHF DISEASE systolic EF 50-55%
* Admission Date: [**2123-2-25**] Discharge Date: [**2123-4-23**]

Date of Birth: [**2040-1-17**] Sex: M

Service: EMERGENCY

Allergies DISEASE :
Aspirin / Codeine / Penicillins / Bactrim / Heparin Agents /
Tetanus

Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
R hip pain DISEASE

Major Surgical or Invasive Procedure:
Closed reduction of right hip
Tracheostomy
Placement of gastric tube
Intubations


History of Present Illness:
83yo Arabic speaking male with multiple medical problems
including dementia HTN COPD GERD DISEASE BPH osteoporosis CKD DISEASE
prior GI bleed DISEASE secondary to ulcer DISEASE [**1-/2120**] and hx of hip
replacement presenting with right hip pain DISEASE . Hip pain started
after bumpy car ride on [**2-19**]. At baseline patient is in
wheelchair and can ambulate with assistance. Since car ride son
has noticed that patient can no longer stand up straight or go
up stairs. Has tried tylenol with little relief for hip pain DISEASE . No
fever/chest pain/SOB/abd pain/new focal neurologic changes.
Currenly DISEASE on lovenox for PE diagnosed in [**Month (only) 205**] also getting
dressing changes for bilateral shin ulcers DISEASE and a coccyx ulcer DISEASE .
The patient's mental status is at baseline per son.

In the ED initial vs were: T 99 P 93 BP 131/79 R 20 O2 sat 98%
on RA DISEASE . The patient was given acetaminophen for pain DISEASE Patient was
evaluated by ortho trauma who are planning to attempted a
closed reduction tomorrow AM for a displaced acetabular ring
seen by Xray.


Past Medical History:
1. Hypertension DISEASE .
2. Renal artery stenosis DISEASE .
3. Chronic obstructive pulmonary disease DISEASE .
4. Gastroesophageal reflux disease DISEASE .
5. Chronic constipation DISEASE .
6. Benign prostatic hypertrophy DISEASE .
7. Peptic ulcer disease DISEASE .
8. Insulin resistance.
9. Memory loss DISEASE .
10. Osteoporosis DISEASE .
11. Gait instability with history of falls.
12. History of GI bleed DISEASE secondary to ulcer DISEASE 01/[**2120**].
13. Weight loss DISEASE .
14. Left lower extremity DVT DISEASE .
15. Status post hip fracture DISEASE [**2120**].
16. Chronic kidney disease DISEASE .
17. History of aspiration.
18. Nondisplaced pelvic fracture DISEASE 05/[**2120**].
19. Peripheral vascular disease DISEASE with lower extremity ulcers DISEASE .
20. Renal lesion DISEASE .
21. Pancreatic cystic lesion DISEASE .
22. Pneumonia DISEASE 01/[**2122**].
23. PE in [**7-/2122**] on lovenox
.
PAST SURGICAL HISTORY:
1. Right cataract DISEASE removal.
2. Right total hip arthroplasty 01/[**2120**].
3. Inguinal hernia DISEASE repair.


Social History:
Smoked for 30 years (heavily). Rare ETOH now. The patient lives
with his son who is the only caretakerAdmission Date: [**2170-3-22**] Discharge Date: [**2170-4-8**]

Date of Birth: [**2102-3-5**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
SOB hypercapnea DISEASE

Major Surgical or Invasive Procedure:
endotracheal intubation


History of Present Illness:
68M with history of COPD DISEASE (on 2-3L O2 at home) with history of
multiple intubations CAD with ischemic cardiomyopathy DISEASE (EF
20-25%) who was transferred to [**Hospital1 18**] from an outside hospital on
[**2170-3-22**] with SOB. Pt initially noted fever DISEASE to 102 4 days prior
to admission. However patient was without respiratory
complaints or cough DISEASE . Pt was started on course of Azithromycin
as an outpatient for suspected bronchitis DISEASE and reports some
improvement in pulm Sx. The evening prior to admisssion the
patient became progressively dyspnic with a minimally-productive
cough DISEASE .

Pt presented to an outside hospital where he was found to have
HR 150 that was believed to be possible Aflutter but per
report was found to be sinus tachcardia DISEASE . CXR per report was
consistent with mild CHF DISEASE and possible RML PNA. ABG on 100% NRB
was 7.25/61/77. Further treamtent at outside hospital included
ASA 325 NTG SL times 2 Alb/Atr nebs Lasix 60 mg IV
Sloumedrol 125mg IV Ceftriaxone and Moxifloxacin. Pt was
subsequently transferred to [**Hospital1 18**] for further management.

On arrival to MICU [**2170-3-22**] pt felt Admission Date: [**2153-3-6**] Discharge Date: [**2153-3-12**]


Service: CCU

CHIEF COMPLAINT: Hypotension DISEASE

HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
with a history of coronary artery disease DISEASE status post
myocardial infarction DISEASE in [**2150**] hypertension DISEASE and
hypercholesterolemia DISEASE recently admitted for evaluation of a
right ankle ulcer/cellulitis DISEASE . She was discharged to home
with Keflex on [**2-24**] with a 7 to 10 day course of antibiotic
scheduled. She was brought in today by her daughter after
being found down in her apartment. The daughter was out of
town for the last five days returned today and found the
patient down on the afternoon of admission. She had seen the
patient the night before and the two had had dinner and there
were no problems at that time. There was no loss of
consciousness. By the patient's report there was no chest
pain shortness of breath nausea vomiting DISEASE no head trauma DISEASE .
By the daughter's report the patient had not been taking any
of her medications for the last five days.

PAST MEDICAL HISTORY:
1. Hypertension
2. Hypercholesterolemia
3. Coronary artery disease DISEASE status post myocardial
infarction DISEASE in [**2150-12-12**]. ETT with inferolateral
reproduced perfusion defect moderate mitral regurgitation DISEASE
mild to moderate AS. Ejection fraction greater than 55% on
[**2150-12-12**].
4. Hypothyroidism DISEASE on chronic replacement
5. Diverticulosis last colonoscopy in [**Month (only) 404**] of '[**49**]
6. External hemorrhoids
7. Status post fall with a pubic ramus fracture DISEASE
8. History of pyuria DISEASE with AFB x3
9. Dementia

ADMISSION MEDICATIONS:
1. Levoxyl 75 mcg po qd
2. Celexa 30 mg po qd
3. Cozaar 25 mg po qd
4. Anusol HC
5. Imdur 30 mg po qd
6. Iron sulfate
7. Lasix 20 mg po qd
8. Lipitor 10 mg po qd
9. MVI 1 tablet po qd
10. Lopressor 25 mg po bid
11. Aspirin 325 mg po qd
12. Keflex 250 mg po qid

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: The patient lives alone. Her daughter is
her healthcare proxy and the telephone number ([**Telephone/Fax (1) 2651**].
There is no tobacco or alcohol history.

PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2184**] [**Last Name (NamePattern1) **]

ADMISSION PHYSICAL EXAM DISEASE :
VITAL SIGNS: Temperature 97.3Admission Date: [**2139-8-20**] Discharge Date: [**2139-8-23**]

Date of Birth: [**2076-7-31**] Sex: M

Service: Cardiothor

HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
male who is otherwise healthy who was evaluated for a
systolic murmur DISEASE . Work up revealed a mitral regurgitation DISEASE
three years ago. He was followed since then but had
worsening symptoms and now came for operative repair.




[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]

Dictated By:[**Last Name (NamePattern1) 3214**]

MEDQUIST36

D: [**2139-8-23**] 10:50
T: [**2139-8-26**] 15:58
JOB#: [**Job Number 3215**]
Admission Date: [**2139-8-20**] Discharge Date: [**2139-8-23**]

Date of Birth: [**2076-7-31**] Sex: M

Service: Cardiothor

HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
male who is otherwise healthy who was evaluated for a
systolic murmur DISEASE . Work up revealed a mitral regurgitation DISEASE
three years ago. He was followed since then but had
worsening symptoms and now came for operative repair.




[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]

Dictated By:[**Last Name (NamePattern1) 3214**]

MEDQUIST36

D: [**2139-8-23**] 10:50
T: [**2139-8-26**] 15:58
JOB#: [**Job Number 3216**]
Admission Date: [**2103-7-26**] Discharge Date: [**2103-8-9**]

Date of Birth: [**2072-5-4**] Sex: F

Service: [**Doctor First Name 147**]

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
abdominal pain DISEASE

Major Surgical or Invasive Procedure:
Status post exploratory laparatomy
status post right colectomy
status post appendectomy
status post abdominal closure


History of Present Illness:
31 yo Female who was status post normal spontaneous vaginal
delivery approximately 10 weeks ago who presented on [**2103-7-25**]
with a chief complaint DISEASE of abdominal pain DISEASE . She was well until
about 12 hours prior to admission when she described the acute
onset of sharp right lower quadrant pain DISEASE and diffuse/poorly
characterized dull general abdominal pain DISEASE . The pain DISEASE was
described as sharp constant. The pain DISEASE radiated to the back.
It got worse with motion better with motrin. The pain DISEASE was
associated with nausea DISEASE and bilious vomiting DISEASE times 1 subsequent
to the onset of pain DISEASE . The patient also described subjective
fevers DISEASE and chills DISEASE . The paitent did not have any constipation DISEASE
diarrhea DISEASE change in the color of her stools dysuria hematuria DISEASE
vaginal discharge itching DISEASE or bleeding DISEASE . No history of recetn
truama travel. she has not been sexually active since her
delivery

Past Medical History:
recurrent respiratory infections DISEASE
allergies DISEASE
Gastroesophageal reflux disease DISEASE
removal of cystic mass DISEASE of breast
removal of labial cyst DISEASE
degenerating fibroid DISEASE during pregnancy

Social History:
works in a research lab
no tobacco or alcohol
travelled to [**Country 2045**] in [**2081**] bermuda in [**2088**]


Family History:
No history of bowel problems DISEASE . Father had a history of
hypertension DISEASE

Physical Exam:
temperature 100.8 pulse 81 blood pressure 109/71 respirations
16 oxygen saturation 100% on room air
General: patient was in moderate distress appeared acutely ill
Head and neck: head atraumatic/normocephalic. sclera anicteric.
No lymphadenopathy DISEASE no jvd
Card: regular rate and rhythm
Lungs: clear to auscultation
Abdomen: soft mildly distended. Diffuse tenderness RLQAdmission Date: [**2133-10-22**] Discharge Date: [**2133-10-26**]

Date of Birth: [**2091-3-27**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Amoxicillin

Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Residual Rt Frontal Mass

Major Surgical or Invasive Procedure:
[**2133-10-22**]: Right Craniotomy for mass resection


History of Present Illness:
Patient is a 42F electively admitted for right craniotomy for
mass resection. She had prior surgery with Dr. [**First Name (STitle) 3228**] on [**10-2**]
but intraop lesion was found to infiltrate the bone table and
brain parenchyma. Surgery was further aborted pending
neurosurgical consultation and planning for complete resection.

Past Medical History:
s/p aborted r frontal mass [**Last Name (LF) 3229**] [**First Name3 (LF) 3228**] [**10-2**] HTN DISEASE
anxiety insomnia DISEASE and hypercholesterolemia DISEASE

Social History:
non-contributory

Family History:
non-contributory

Physical Exam:
Upon discharge:
Alert and oriented to person place and time. MAE with 5/5
strength. Neuro exam is nonfocal intact. Head incision is C/D/I
with dissolveable sutures.
Ambulating steadily with normal gait. Tolerating POs.

Pertinent Results:
Labs on Admisson:
[**2133-10-22**] 05:27PM BLOOD WBC-11.7* RBC-3.94* Hgb-10.9* Hct-33.3*
MCV-85 MCH-27.7 MCHC-32.8 RDW-14.0 Plt Ct-389
[**2133-10-22**] 05:27PM BLOOD Glucose-175* UreaN-10 Creat-0.7 Na-144 DISEASE
K-4.5 Cl-111* HCO3-25 AnGap-13
[**2133-10-22**] 05:27PM BLOOD Calcium-9.3 Phos-3.9 Mg-1.7

Imaging:
Post-op MRI [**10-23**]: IMPRESSION: Expected post-surgical changes
are seen following resection of a large bony tumor DISEASE within the
skull in the right frontoparietal region. Pneumocephalus and
small amount of blood products are seen in the region. No acute
infarcts DISEASE or hydrocephalus DISEASE .


Brief Hospital Course:
Patient was electively admitted for completion of right sided
tumor DISEASE resection. Post-operatively she was observed in the ICU
for 24 hours. On POD#2 she was transfer to the NSURG floor
neuro exam remained intact. Post-operative MRI revealed complete
resection of the lesion. She tolerated POs and was cleared by
PT for discharge home. She was discharged on [**2133-10-26**].

Medications on Admission:
Acyclovir [**Doctor Last Name **]
Fluticasone nasal spray
HCTZ 25mg daily
Labetolol 100mg [**Hospital1 **]

Discharge Medications:
1. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
2. Acetaminophen 160 mg/5 mL Solution Sig: [**12-26**] PO Q6H (every 6
hours) as needed for pain/TAdmission Date: [**2144-8-24**] Discharge Date: [**2144-8-27**]

Date of Birth: [**2097-5-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Heparin Agents / Codeine / Zosyn / Ceftriaxone

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Hypoxia DISEASE and Eosinophilia DISEASE


Major Surgical or Invasive Procedure:
bronchoscopy

History of Present Illness:
The patient is a 47y/o F with a PMH of EtOH abuse recent
hospitalization for PNA presenting with hypoxia DISEASE . The patient was
hospitalized [**Date range (1) 3246**] after presenting with fever chills DISEASE and
SOB. She had been staying at an etoh rehab facility on [**Hospital3 **]
starting [**7-12**]. She presented to [**Hospital3 **] hospital on [**7-30**] with
CP and fever DISEASE to 102. CXR at that time demonstrated a PNA and she
was given a course of ceftriaxone-Admission Date: [**2170-8-20**] Discharge Date: [**2170-8-25**]

Date of Birth: [**2096-8-16**] Sex: M

Service:

CHIEF COMPLAINT: Bright red blood per rectum.

HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman
with a history of bleeding DISEASE internal hemorrhoids status post
cauterization seven days prior to admission who was started
on Plavix three days prior to admission. He was admitted to
the medical Intensive Care Unit for bright red blood per
rectum. The patient said the bleeding DISEASE started suddenly at 2
o'clock PM on the day of admission with passing large clots
and bright red blood per rectum. This was not associated
with abdominal pain nausea fevers chills diarrhea DISEASE . The
patient reports he has bright red blood per rectum on a daily
basis this is basically self-limited.

REVIEW OF SYSTEMS: The patient complains of severe rectal
pain DISEASE . No complaints of chest pain dyspnea DISEASE short of breath
or dysuria DISEASE .

In the emergency department the patient continued to have
profuse bright red blood per rectum and was transfused two
units of packed red blood cells. His blood pressure had
decreased systolic blood pressure in the 80's which was
corrected by fluid boluses. Colonoscopy revealed an actively
bleeding DISEASE internal hemorrhoid which was ligated.

PAST MEDICAL HISTORY:
1. Internal hemorrhoids.
2. Diverticula and polyp DISEASE seen on [**6-21**] colonoscopy.
3. Chronic renal insufficiency DISEASE with a baseline creatinine of
2 to 3 thought to be secondary to hypertensive DISEASE glomerulus
scleras.
4. Atrial fibrillation DISEASE .
5. Cerebrovascular accident on [**7-22**].
6. Obstructive sleep apnea intolerance of CPAP.
7. Hypercholesterolemia.
8. Anemia.

ALLERGIES: No known drug allergies.

MEDICATIONS:
1. Plavix 75 mg p.o. q day.
2. Diovan 80 mg p.o. q day.
3. Allopurinol 100 mg p.o. q day.
4. Zantac.
5. Lipitor.
6. Epoetin 10000 units q week.
7. Iron.

SOCIAL HISTORY: The patient lives with his wife. Quit
smoking several years ago no alcohol no intravenous drug
use.

PHYSICAL EXAMINATION: On admission temperature was 97.4
blood pressure 192/47 heart rate 16 sating 100% on two
liters nasal cannula. General: Alert and oriented times
three. Some discomfort in the rectal area. Head eyes
ears nose and throat: Pupils are equal round and reactive
to light and accommodation. Extraocular movements DISEASE intact.
Dry mucous membranes. Neck: Supple no lymphadenopathy DISEASE or
jugular venous distention DISEASE . Pulmonary: Clear to auscultation
bilaterally. Cardiac: Bradycardiac. Regular. S1 and S2.
No murmurs rubs or gallops. Abdomen: Obese nontender.
Normal active bowel sounds DISEASE no organomegaly DISEASE . Extremities:
No cyanosis clubbing DISEASE or edema DISEASE . 2Admission Date: [**2172-1-5**] Discharge Date: [**2172-2-13**]

Date of Birth: [**2096-8-16**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Weakness / confusion DISEASE

Major Surgical or Invasive Procedure:
Placement of a SVC tunnelled hemodialysis catheter
Placement of a subclavian central line
Placement of a percutaneous cholecystostomy
Intubation
Placement of a femoral central line


History of Present Illness:
This 75 year old man with a past medical history significant for
CVA atrial fibrillation DISEASE and chronic renal insufficiency DISEASE
presented with worsening confusion DISEASE & agitation DISEASE x 1 day. He also
had headache nausea DISEASE unsteady gait dyspnea on exertion and
dizziness DISEASE . His wife called the patient's primary care doctor
who referred them to the emergency department. According to the
patient's wife these symptoms had been getting progressively
worse over the past 3 weeks. The patient denied pruritis DISEASE chest
pain shortness of breath or abdominal pain DISEASE .
.
The patient was seen by his PCP [**Last Name (NamePattern4) **] [**2172-1-2**] (3 days prior to
admission) and at that time had malise fatigue poor appetite
difficulty walking and nausea DISEASE . He had an unchanged MRI of his
head at that time and his BUN/cr were elevated but close to his
baseline 78 & 5.7 respectively). During that office visit he
denied shortness of breath chest pain abdominal pain nausea DISEASE
or diarrhea DISEASE . He did mention that he had started taking
amitriptyline one week prior.

Past Medical History:
- cerebrovascular accident with residual aphasia DISEASE
- atrial fibrillation DISEASE
- hypertension DISEASE
- chronic renal insufficiency DISEASE (creat baseline 5.0-5.3)
- Anemia DISEASE
- Gout DISEASE

Social History:
lives with wife lives on [**Location (un) 470**] with elevator

Family History:
Non-contributory

Physical Exam:
VS: afebrile vital signs stable
HEENT: NCAT PERRL anicteric EOMI MMM
Neck: supple no LAD no JVD no carotid bruits DISEASE
Resp: Bibasilar crackles
Cards: RRR nl S1 S2 no m/g/r
Abd: nl BS soft NT ND no HSM
Ext: no edema DISEASE Admission Date: [**2147-12-6**] Discharge Date: [**2147-12-9**]

Date of Birth: [**2110-3-12**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
lethargy DKA DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
37F with PMH DM1 DISEASE transferred from OSH for lethargy DISEASE and DKA DISEASE . Pt
relates that last week she developed severe headaches DISEASE for which
her PCP got an MRI and diagnosed her with cluster headache DISEASE . She
had a tooth filled 3 week prior and last week damaged the tooth
opening a bottle with it. Her dentist again filled the tooth
last Friday and over the past week she has been treated for a
right sided tooth infection DISEASE initially with amoxicillin but she
developed worsened pain DISEASE and was switched to flagyl. On Saturday
she noted significantly increased right sided facial swelling
and pressure. Two days prior to admission she experienced
drainage of purulent material from the gums surrounding the
infected tooth DISEASE . Denies fever chills diarrhea dysuria DISEASE pelvic
pain cough DISEASE sputum production. She concommitently developed
fatigue lethargy vomiting nausea DISEASE with decreased PO intake.
She has been taking her usual insulin regimen of lantus 16 Qhs
plus mealtime lispro 3-5unit SS with finger sticks not above
208. At the OSH labs included glucose 389 AG 18 for which she
got 4L IVF 6U IV insulin started on insulin gtt.
.
In the ED inital vitals were T 98.9 HR 115 BP 118/74 RR 20 Sat
100%RA FSG 172. Insulin drip was stopped but was restarted with
D5NS Admission Date: [**2201-4-2**] Discharge Date: [**2201-4-20**]

Date of Birth: [**2138-12-24**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Left hip pain DISEASE

Major Surgical or Invasive Procedure:
s/p L hip resection


History of Present Illness:
yo male with history of HTN DISEASE GERD EtOH cirrhosis Crohn's DISEASE s/p
ileostomy COPD depression pancytopenia avascular necrosis DISEASE
[**1-7**] chronic prednisone use s/p L hip replacement presenting
originally for planned L hip revision but was found unable to
be revised because of advanced osteolysis DISEASE and so is now s/p
total resection arthroplasty. Patient noted to be confused
overnight. Per ortho team patient had also been confused on
coming out of the OR on [**2201-4-2**] but his mental status cleared
up overnight. Had initially been transferred to ICU post surgery
because of hypotension DISEASE was on pressors with subsequent
normalization of blood pressures and transferred to floor team
on [**2201-4-5**]. He has been quite lucid until last night when he was
again noted to be confused trying to get out of bed and seeing
people in his room.
.
Per prior report patient himself says that he feels fatigued
since his surgical procedure finding that he falls asleep a
lot. Has been having nightmares DISEASE and Admission Date: [**2201-6-23**] Discharge Date: [**2201-6-29**]

Date of Birth: [**2138-12-24**] Sex: M

Service: ORTHOPAEDICS

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 64**]
Chief Complaint:
R hip pain DISEASE

Major Surgical or Invasive Procedure:
[**2201-6-23**]: s/p left total hip revision


History of Present Illness:
62 year old man with [**First Name9 (NamePattern2) 3262**] [**Last Name (un) 3263**] cirrhosis DISEASE c/b Grade 1 esophageal
varices and past GIB DISEASE 's Crohn's DISEASE s/p ileostomy COPD HTN DISEASE
pancytopenia DISEASE GERD depression avascular necrosis DISEASE [**1-7**] chronic
prednisone use s/p L hip replacement with massive osteolysis DISEASE of
pelvis/acetabulum and proximal femur extended femoral osteotomy
(clamshell) with multiple open reduction and internal fixations
who is admitted to the ICU for monitoring after 3rd attempt of
total hip replacement.
.
The patient was previously discharged on [**2201-4-20**] s/p total
resection arthroplasty on [**2201-4-2**]. Post-operatively the patient
was noted to be confused coming out of the OR and overnight. He
was initially transferred to ICU post surgery because of
hypotension DISEASE and was on pressors with subsequent normalization of
blood pressures. Post-op course was also complicated by
hepatic/toxic-metabolic encephalopathy DISEASE cleared with rifaximin
and lactulose and by acute kidney injury DISEASE .

Past Medical History:
Past Medical History:
- HTN DISEASE
- dyslipidemia DISEASE
- ascending aortic aneurysm DISEASE not involving the coronary vessels
- bicuspid aortic valve
- EtOH cirrhosis c/b esophageal varices DISEASE and bleeding DISEASE : baseline
liver enzymes ALT 21 AST 30 ALK 190 TBili 1.2
- pancytopenia DISEASE : baseline WBC 1.7 Hgb 12.3 Hct 35.8 Plt 54
- thrombocytopenia DISEASE
- Crohn's disease DISEASE s/p ileostomy
- prostate cancer DISEASE
- kyphosis DISEASE
- COPD DISEASE
- GERD
- squamous cell carcinoma DISEASE s/p resection
- avascular necrosis DISEASE of left hip secondary to prednisone
- depression DISEASE
- baseline BUN 15 Cr 1.0
.
Past Surgical History:
- squamous cell carcinoma DISEASE excisions x 3 forehead ([**10/2199**])
- L distal radius ORIF ([**2196**])
- partial colectomy with transverse colostomy and mucous fistula DISEASE

- mucous fistula takedown
- left wrist surgery
- left hip replacement (20 years ago)
- avascular necrosis of left hip secondary to
Crohn's/prednisone
- Complex complete resection arthroplasty of failed left total
hip replacementAdmission Date: [**2181-5-6**] Discharge Date: [**2181-5-11**]

Date of Birth: [**2103-9-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
mental status change

Major Surgical or Invasive Procedure:
endoscopy


History of Present Illness:
77 M with pmhx of pulmonary fibrosis CHF DISEASE presents with one
week history of altered mental status increasing lethargy DISEASE and
confused speech. He was brought to his PCP (Dr. [**Last Name (STitle) 3267**] for
evaluation and was referred for a Head CT on 2 days PTA
negative. On the DOA he was found by his son to be slumped in
bed minimally responsive confused with bowel incontinence DISEASE
and brought to the ED. No report of LOC trauma DISEASE fevers chills
has had continued good PO intake no diarrhea DISEASE per report or
cp/sob

In ED VS 97.8 57 184/40 100% 2L given levaquin NS lactulose
head CT was negative. NGL was negative.

He was taken to MICU for closer monitoring. TBili was elevated
and ammonia was 114. RUQ U/S revealed chronic liver disease DISEASE
changes and hepatology was consulted.

Upon improvement of mental status with lactulose he was
transferred back to the floor. On the floor he has no
compliants of pain DISEASE . He denies any F/C/N/V abd pain DISEASE . He does
note feeling very thirsty.


Past Medical History:
Interstitial Fibrosis DISEASE
CHF DISEASE


Social History:
Lives with wife (with alzheimers) son lives 3 blocks away
independant own ADLs was driving up to 1 week ago DC'd Etoh 5
yrs ago was told to stop o/w [**2-3**] drinks/day quit smoking 25
yrs ago but o/w 1-2ppd smoker.

Family History:
Brother died 40s CAD
Father died 40s CAD
1 Sister healthy


Physical Exam:
VS 98.9 98.9 154-187/71-76 68 18 99%2L
GEN: slightly agitated
HEENT: PERRL EOMI icteric sclera dry MM DISEASE OP with thrush DISEASE
CV: RRR SEM III/VI radiating R carotid
ABD: Admission Date: [**2181-5-14**] Discharge Date: [**2181-5-20**]

Date of Birth: [**2103-9-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
readmit for mental status changes

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
77 year-old M with chronic liver disease pulmonary fibrosis DISEASE
and CHF DISEASE who presented with altered mental status. He was
recently discharged (hospitalized from [**Date range (1) 3270**]) from the
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service for altered mental status increased
lethargy DISEASE and confusion DISEASE which was attributed to hepatic
encephalopathy DISEASE and UTI DISEASE . Prior to his admission on [**2181-5-6**] the
patient was taking Spironolactone 50 mg daily and Atenolol 50
mg daily. Ammonia level on prior admission was 114 and total
bilirubin 4.0. RUQ U/S revealed changes c/w chronic liver
disease patent portal vein and cholelithiasis DISEASE . EGD revealed e/o
portal gastropathy varices DISEASE in the lower and middle thirds of
the esophagus and esophagitis DISEASE . Also of note he was
thrombocytopenic DISEASE which was attributed to chronic liver disease DISEASE .
Lipid panel revealed high LDL. He also had Guaiac positive
stools. Mental status improved with lactulose. He was started on
nadalol and a PPI. Hepatitis A DISEASE & B serologies were sent and
unremarkable. A1AT was 72 (83-199) [**Doctor First Name **] titer was 1:40.
Hereditary hemochromatosis DISEASE mutational analysis was sent.
.
The patient was discharged to rehab on [**2181-5-11**]. On the day of
current admission ([**2181-5-13**]) the NH reports that the patient had
increased lethargy DISEASE and poor appetite. He was found to be 95% on
2L NC. He complained of indigestion to the staff. Per his
family he also had chest pain DISEASE the day PTA. Labs demonstrated a
leukocytosis DISEASE and worsening LFTs. He received Vancomycin 1 g
levofloxacin 750 mg and Flagyl 500 mg in the ED. He was
transferred to the MICU for further management. Cardiology was
consulted for possible STEMI but did not recommend
catheterization for what is felt to be a recent posterolateral
MI. RUQ U/S was limited by gaseous abdominal distension DISEASE but
revealed normal CBD (5mm) and two hypoechoic nodules within the
right liver lobe. Pt denies N/V/orthopnea/platypnea DISEASE .


Past Medical History:
Interstitial Fibrosis DISEASE
CHF DISEASE


Social History:
Lives with wife (with alzheimers) son lives 3 blocks away
independant own ADLs was driving up to 1 week ago DC'd Etoh 5
yrs ago was told to stop o/w [**2-3**] drinks/day quit smoking 25
yrs ago but o/w 1-2ppd smoker

Family History:
Brother died 40s CAD
Father died 40s CAD
1 Sister healthy


Physical Exam:
Vitals: T: 97.3 BP: 114/52 (114-125/39-65) P: 67 (65-73) RR:
16 (14-21) SaO2: 98% 3L NC I/O: 4267/645 (UOP Admission Date: [**2161-3-2**] Discharge Date: [**2161-3-8**]

Date of Birth: [**2089-11-15**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
nausea vomiting DISEASE

Major Surgical or Invasive Procedure:
s/p suboccipital craniotomy for tumor DISEASE resection and biopsy


History of Present Illness:
71F with NSCLC HTN hypercholesterolemia DISEASE admitted with
refractory nausea/vomitting since starting Tarceva. She denies
abdominal/chest pain DISEASE SOB diarrhea/constipation or problems
w/bladder incontinence DISEASE . She does have unsteadiness of gait DISEASE as
well as trouble using her right hand.

Past Medical History:
1. NSCLC DISEASE : prior w/u at [**Hospital1 112**]/[**Company 2860**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3273**])- lung
nodules found on preop CXR [**6-14**] CT showed RLL nodule c/w
primary lung cancer DISEASE and multifocal bronchoalveolar carcinoma DISEASE
PET/CT showed FDG-avid R lung nodule and mediastinal/pericardial
LAD s/p bronch/mediastinoscopy with mediastinal LN dissection
with path showing NSCLC-adenocaAdmission Date: [**2103-11-12**] Discharge Date: [**2103-11-22**]

Date of Birth: [**2072-5-4**] Sex: F

Service: SURGERY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
ileostomy in place from [**9-3**]

Major Surgical or Invasive Procedure:
ileostomy takedown on [**2103-11-12**]


History of Present Illness:
31F had an appendectomy with right colectomy in [**8-4**] with
ileostomy placement. She is here now for takedown of the
ileostomy.

Past Medical History:
recurrent respiratory infections DISEASE
allergies DISEASE
Gastroesophageal reflux disease DISEASE
removal of cystic mass DISEASE of breast
removal of labial cyst DISEASE
degenerating fibroid DISEASE during pregnancy

Social History:
works in a research labno tobacco or alcoholtravelled to [**Country 2045**]
in [**2081**] bermuda in [**2088**]

Family History:
No history of bowel problems DISEASE . Father had a history of
hypertension DISEASE

Physical Exam:
temp 99.8 HR 80 BP 110/72 RR 16 oxygen 100% RA DISEASE
General: NAD
Head and neck: head atraumatic/normocephalic sclera anicteric
No lymphadenopathy DISEASE no jvd
Card: regular rate and rhythm with s1s2
Lungs: clear to auscultation b/l
Abdomen: soft non-distended ileostomy in place
Back: no costovertebral angle tenderness
Extremeties: no edema DISEASE no cyanosis DISEASE no clubbing DISEASE
Neuro: A Admission Date: [**2118-10-23**] Discharge Date: [**2118-10-30**]

Date of Birth: [**2065-7-31**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 3290**]
Chief Complaint:
cough respiratory distress DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
53 yo M w/ h/o Down's syndrome DISEASE non-verbal at baseline
hypothyroidism cataracts dysphagia DISEASE s/p G-tube h/o aspiration
pna's hypoNa on 4Lnc QHS who presents w/ cough DISEASE and hypoxia DISEASE from
group home.
.
Per report patient with acute on chronic cough DISEASE found to desat
to 88% on RA DISEASE this AM. Looked as if he were in respiratory
distress. Per OMR had been empirically treated for pna back in
[**6-/2118**] w/ multiple notes documenting cough DISEASE .
.
In the ED initial VS were: 98.2 74 92/50 28 100% nrb. Tmax
100.2. On exam Admission Date: [**2119-9-10**] Discharge Date: [**2119-9-15**]

Date of Birth: [**2065-7-31**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
respiratory distress DISEASE

Major Surgical or Invasive Procedure:
Right internal jugular line ([**9-10**])

History of Present Illness:
53 yo M w/ h/o Down's syndrome DISEASE non-verbal at baseline
hypothyroidism cataracts dysphagia DISEASE s/p G-tube h/o aspiration
pna's hypoNa on 4Lnc QHS who presents w/ cough DISEASE and hypoxia DISEASE from
group home.

Per report patient with acute on chronic cough DISEASE found to desat
to 88% on RA DISEASE this AM. Looked as if he were in respiratory
distress. Per OMR had been empirically treated for pna back in
[**6-/2118**] w/ multiple notes documenting cough DISEASE .

In the ED initial VS were: 98.2 74 92/50 28 100% nrb. Tmax
100.2. On exam Admission Date: [**2167-11-5**] Discharge Date: [**2167-11-9**]

Date of Birth: [**2087-3-14**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
urosepsis DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
80 Russian female with h/o CAD AF s/p PPM HTN CHF DISEASE (EF
45-50%) CRI (Cr 1.5) lung CA s/p resection in [**2153**] chronic
pain DISEASE who presents to the ED with complaints of progressive LE
pain DISEASE and weakness DISEASE over the past several days to weeks. She also
c/o incresing DOE at home now limited to [**1-30**] steps. She has
been sleeping in a recliner recently with her husband helping
her with most ADLs.
.
She also complained difficulty urinating recently as well as
some constipation DISEASE . The constipation DISEASE is not new and it can be 4
days between bowel movements DISEASE . The urinary difficulties DISEASE include
both getting to the bathroom in time (due to pain DISEASE and DOE) as
well as the sensation that she does not completely void. She has
no dysuria DISEASE . The swelling DISEASE in her legs is associated with mild
increase in pain DISEASE and redness as well as itching. Her back pain DISEASE
has been worse.
.
She was recently admitted to [**Hospital1 18**] cardiology service and d/c on
[**2167-10-12**]. She was dx with CHF DISEASE and her medication regimen was
adjusted.
.
Cardiac ROS: She describes intermittent chest pain DISEASE with
activity marked DOE with minimal activity positive orthopnea
and PND and has a h/o claudication though pain DISEASE is different
now. She would intermittently hold her BP meds (ie metoprolol)
b/c Admission Date: [**2183-10-2**] Discharge Date: [**2183-10-4**]

Date of Birth: [**2115-3-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamides) / Adhesive Tape / Iodine

Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Syncope DISEASE and chest pain DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 3311**] is a 68 yo man with a history of severe CAD s/p MI
3V CABG (LIMA-LAD SVG-RCA sequential SVG-D1-OM) in [**2169**] and
multiple PCIs who presents with acute onset chest pain DISEASE . The
patient states that he was in his usual state of health when he
woke up this morning [**10-2**]. He was in his kitchen when the next
thing he knew he woke up on the floor. He denies any prodrome
including dizziness lightheadedness vertigo DISEASE focal weakness
or aura. He does not know how long he was unconscious but when
he awoke he was experiencing acute onset [**10-8**] retrosternal
chest pain DISEASE . The pain DISEASE was diffuse and located at the midline. It
was not positional and was not acutely associated with nausea DISEASE or
vomiting DISEASE . It did radiate up to his jaw which alarmed him since
this was exactly what he experienced when he had his MI. He does
not think he fell on his chest. He was able to get up on his
own climb the stairs and call EMS.

He was brought to [**Hospital3 **] where he was given ASA and
nitro SL without relief of his chest pain DISEASE . He was started on a
TNG drip but still complained of [**10-8**] pain DISEASE . EKG showed
ventricularly paced rhythm with no acute ST or QRS changes from
prior. A Troponin-I measurment was 0.14. Myoglobin was 103. His
INR was 4.3. An ABG on 2L NC at that time was 7.32/46/95/24/Sat
97%. He was subsequently transferred to [**Hospital1 18**] for possible
catheterization.

On review of symptoms he denies any prior history of stroke DISEASE
TIA DISEASE deep venous thrombosis pulmonary embolism bleeding DISEASE at the
time of surgery cough hemoptysis DISEASE black stools or red stools.
He denies recent fevers chills DISEASE or rigors DISEASE . He is unable to walk
very far due to left leg pain DISEASE but states this is due to an
established neuropathy DISEASE . All of the other review of systems were
negative.

Cardiac review of systems is notable for absence of dyspnea DISEASE on
exertion paroxysmal nocturnal dyspnea orthopnea DISEASE ankle edema DISEASE
palpitations DISEASE .

Past Medical History:
-CAD s/p MI
-CABG [**2169**] (LIMA-LAD SVG-RCA SVG-D1-OM)
-Hypertension
-Hyperlipidemia
-Atrial tachycardias DISEASE s/p ablation followed by atrial
fibrillation/flutter DISEASE with AV nodal ablation s/p pacer [**2177 DISEASE **] on
warfarin
-Neuropathy
-Gout
-Depression and anxiety DISEASE

Social History:
significant for the absence of current tobacco use (smoked from
age 16-46 at 1 ppd). There is no history of alcohol abuse.

Family History:
There is no family history of premature coronary artery disease DISEASE
or sudden death.

Physical Exam:
Gen: WDWN middle aged Caucasian male in NAD mild distress
mildly diaphoretic. Oriented x3. Mood affect appropriate.
Pleasant.
VS: T 96.6 BP 126/77 HR 84 RR 21 O2 sat 100% on 5 L/min NC
HEENT: NC/AT. Sclera anicteric. PERRL EOMI. Conjunctiva were
pink no pallor DISEASE or cyanosis DISEASE of the oral mucosa.
Neck: Supple with JVP of 7 cm. No carotid bruits DISEASE .
CV: PMI located in 5th intercostal space midclavicular line.
RR normal rate. Normal S1 S2 no murmurs rubs or gallops.
Chest: Pacemaker palpable in L upper chestAdmission Date: [**2119-10-2**] Discharge Date: [**2119-10-13**]

Date of Birth: [**2043-5-9**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Lasix

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain shortness of breath DISEASE

Major Surgical or Invasive Procedure:
[**2119-10-5**] Aortic Valve Replacement(21mm Porcine). Mitral Valve
Replacement(29mm Porcine). Two Vessel Coronary Artery Bypass
Grafting utilizing the LIMA to LAD and vein graft to obtuse
marginal.
[**2119-10-2**] Cardiac Catheterization


History of Present Illness:
Mr. [**Known lastname 3315**] is a 76 year old male with chronic diastolic
congestive heart failure(aortic stenosis mitral regurgitation DISEASE )
and chronic atrial fibrillation DISEASE who presented to outside
hospital with progressive shortness of breath and chest pain DISEASE for
the last six months. He admits to occasional rest pain DISEASE as well.
During that admission he was found to be anemic and transfused
with several units of PRBC's. Endoscopy found a nonbleeding AV
malformation DISEASE in the proximal duodenum. Given his above cardiac
status he was transferred to the [**Hospital1 18**] for further evaluation
and treatment.

Past Medical History:
-Coronary Artery Disease prior PCI
-Aortic Stenosis
-Mitral Regurgitation
-Chronic Diastolic Congestive Heart Failure DISEASE
-Cerebrovascular Disease DISEASE prior TIA DISEASE 's s/p right carotid stent
s/p Right CEA
-Hypertension
-Dyslipidemia
-Chronic Atrial Fibrillaton DISEASE
-Chronic Renal Insufficiency
-COPD
-Anemia
-History of GIB AV DISEASE Malformation(duodenum)
-BPH s/p TURP


Social History:
Lives alone. Quit tobacco about one months ago prior heavy
tobacco use. He denies ETOH.

Family History:
Father died at age 36 from MI.

Physical Exam:
Admit PE: 5'[**22**]Admission Date: [**2126-10-3**] Discharge Date: [**2126-10-12**]


Service: MEDICINE

Allergies DISEASE :
Penicillins / Lopressor

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
hematemesis DISEASE

Major Surgical or Invasive Procedure:
EGD s/p sclerotherapy


History of Present Illness:
81y/o M with h/o diverticular bleed DISEASE presented to ED with melena DISEASE
and BRBPR x1 day. Pt felt lightheaded but denied CP
palpitations DISEASE or dyspnea DISEASE at rest. Admission Date: [**2110-5-21**] Discharge Date: [**2110-5-23**]

Date of Birth: [**2050-3-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Lightheadedness slow pulse

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Dr. [**Known lastname 3339**] is a 60 yoM with a history of myxomatous mitral
valve disease DISEASE s/p annuloplasty '[**98**] paroxysmal atrial DISEASE
fibrillation DISEASE currently on Dronedarone and Coumadin h/o
postoperative NSVT DISEASE s/p ICD placement and h/o nondilated
cardiomyopathy DISEASE with EF who presents with lightheadedness DISEASE and
near-syncope in the context of recent undefined illness DISEASE and
weight loss DISEASE .
.
Pt reports history of 25lb weight loss DISEASE in the past 6 weeks that
he attributes to losing his sense of taste due to his
Parkinson's DISEASE meds. He denies any further focal symptoms during
this time frame. Then today he was not feeling well while at
work in the ED here at [**Hospital1 18**]. He had been feeling lightheaded
all day. He went home then relates that he was laying on the
couch watching TV with his daughter and may have passed out for
some time the only thing he remembers is his daughter waking
him up. He is unsure if he actually lost consciousness or not. A
family member took his pulse and found him to be in the 20's so
brought him to the ED.
.
There his vitals were hr 31 110/68 18 100% RA DISEASE . He was found
to have elevated INR hypokalemic DISEASE and repleted. EKG showing
sinus bradycardia DISEASE with intermittent ventricular escape beats DISEASE and
Vpaced beats. He is admitted to CCU for pacer interrogation and
monitoring.
.
ROS is positive as above and also with worsening postural
hypoTN which he ascribes to the Parkinson's meds and lost of
taste also attributed to Parkinson's meds
.
ROS is negative for f/c/ns CP SOB diaphoresis cough DISEASE PND
orthopnea syncope DISEASE


Past Medical History:
1. Myxomatous mitral valve disease DISEASE status post mitral valve
repair with an annuloplasty ring at the [**Hospital 3340**] Clinic in
[**2098**].
2. Postoperative nonsustained VT status post single chamber
[**Company 1543**] ICD generator changed in [**2108**].
3. Atrial fibrillation DISEASE was previously on Amiodarone but now on
Dronedarone and also Coumadin
4. Nonischemic dilated cardiomyopathy DISEASE with an ejection fraction
of 30-40%
5. Parkinson disease DISEASE recently initiated on Aricept and
carbidopa
6. Progressive orthostasis DISEASE with dizziness DISEASE upon standing.
7. Small ASD DISEASE or PFO DISEASE not felt to be clinically significant

Social History:
Lives at home with wife and two daughters
[**Name (NI) 1139**] Use: Never smoker
Alcohol Abuse: No history of alcohol abuse DISEASE .
No drugs

Family History:
FH DISEASE :
h/o colon CA


Physical Exam:
96.5 72 116/74 15 99% RA DISEASE
Pleasant middle aged male in no distress good historian.
JVD not elevated no hepatojugular reflux noted
Lungs CTAB no w/c/r/r good air movement no accessory muscle
use breathing comfortably on room air
RRR no murmurs appreciated heart sounds soft S1 S2 no S3 S4
Abd obese NT ND
No BLE edema noted but hyperpigmented macules noted
2Admission Date: [**2196-4-23**] Discharge Date: [**2196-6-14**]


Service:

HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old
male admitted earlier then anticipated because of failure DISEASE to
thrive respiratory difficulties peripheral edema DISEASE and
pericardial effusion DISEASE after having been discharged for a prior
hospitalization for aspiration pneumonia DISEASE where he was found
to have a collapse of his left main stem bronchus distal
trachea and right main stem bronchus for which he
subsequently had a stent placed during that previous visit.
He returned on [**4-23**] of [**2195**] earlier then anticipated as
mentioned previously for removal of these stents and
tracheoplasty and pericardiotomy for intraoperative
pericardiotomy for pericardial effusion DISEASE that he developed.

At the time of his admission the patient was afebrile with
blood pressure 150/80 pulse 70 respiratory rate 20 and he
was sating 95% on room air. Notably on examination his
cardiac examination revealed an irregularly irregular rhythm.
The lungs revealed bilateral crackles throughout and there
was 1 to 2Admission Date: [**2198-2-13**] Discharge Date: [**2198-2-20**]


Service: SURGERY

Allergies DISEASE :
Zestril

Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Lyphoma scheduled palliative splenectomy

Major Surgical or Invasive Procedure:
Open splenectomy


History of Present Illness:
80 yo M with known lymphoma DISEASE in need of splectomy

Past Medical History:
1. Congestive Heart Failure DISEASE
2. HTN DISEASE
3. s/p Tracheal reconstruction
4. Spinal stenosis DISEASE s/p laminectomy
5. Chronic Renal Failure DISEASE with baseline creatinine in mid 2's.
6. BPH
7. CAD s/p LAD PTCA in '[**91**]. Stress in [**2194**] with normal EF and
fixed inferior perfusion defect.
8. Anemia DISEASE
9 PAF not on anticoagulation
10. Depression DISEASE
11. OSA DISEASE


Social History:
Lives with his wife but son visits daily. Walks with walker at
baseline. Remote tobacco history. Drinks approximately 2 glasses
of vodka per week.

Family History:
Non-contributory

Physical Exam:
(pre-op)
96.4 120/50 82 24 94%RA
NAD age-appropriate
HEENT: MMM minimal periorbital edeam ATNC
CTA-B with decreased BS Admission Date: [**2163-2-22**] Discharge Date: [**2163-2-27**]

Date of Birth: [**2086-12-13**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamide Antibiotics) / Percocet / Lipitor / Zocor

Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
fatigue anorexia DISEASE worsening lung lesions DISEASE from imaging

Major Surgical or Invasive Procedure:
Bronchoscopy with biopsy and BAL
Pigtail catheter placement to treat iatrogenic pneumothorax DISEASE


History of Present Illness:
76 year old female with h/o hypothyoidism HTN/HLP AAA repair
in past with notable known lung adenoCA and new RLL lung mass
which has enlarged in size over the last 4 months being
followed by Dr. [**Last Name (STitle) **] in oncology who presented to Dr.[**Name DISEASE (NI) 3371**]
clinic today for follow-up of recent multiple ground glass
opacities DISEASE and recent biopsy of RL lung with c/o progressive
night sweats anorexia weakness DISEASE . Pt is being admitted directly
from oncology clinic for further evaluation and inability to
care for herself at home secondary to weakness DISEASE . Notable results
from recent biopsy revealed new squamous cell CA (different than
prior adenoCA).
.
Regarding the patient's symptoms - noted last seen by Dr. [**Last Name (STitle) **]
3wks prior - with progressive symptoms of fatigue DISEASE wt loss (10
lb past 6 mo) NS decreasing BP with PCP down titrating BP meds
recently. Overall symptoms had started [**4-10**] mo ago with
rhinorrea dry cough DISEASE ear pain DISEASE all without fevers DISEASE - tx with
several courses of azithromycin/levofloxacin. In addition with
progressive fatigue DISEASE - pt with further difficulty ambulating 50m
more due to gen decreased strength no focal symptoms does have
mild DOE without SOB at rest productive cough/hemopytosis. Pt
with general mild mid-lower back pain DISEASE without any current CP
complaints presently. Pt denies any current ear pain DISEASE HA or
sinus complaints DISEASE . Note patient has not taken any of her home
medication yet today at time of evaluation.
.
ROS: Denies skin changes changes in urination DISEASE or bowels
otherwise 10-point ROS is negative except as detailed above.

Past Medical History:
Onc PHMx:
.
1. Stage I adenocarcinoma of the lung DISEASE 1.5 cm in [**2154**] (stage
IA).
Did not receive adjuvant therapy. Tumor DISEASE harbors had a KRAS
mutation and was EGFR wild-type.
2. Multiple pulmonary ground glass opacities DISEASE with indolent
growth
pattern (unclear etiology thought to be possible
adenocarcinomas DISEASE ) since [**2154**].
3. Stage I (T1c N0 M0) ER/PR positive HER-2/neu positive
breast cancer DISEASE of the left breast in [**2148**].
4. Possible early stage squamous cell carcinoma DISEASE of the lung
diagnosed on [**2163-2-11**] (growing right lower lobe lesion).
.
TREATMENTS:
1. Status post adjuvant hormone therapy (tamoxifen) from [**2148**] to
[**2150**] for her stage I breast cancer DISEASE .
2. Status post right lower lobe wedge resection in [**2155-1-27**].
3. Status post erlotinib 150 mg/day from [**4-2**] to [**2156-4-22**]
(intolerant to medication due to grade [**2-6**] rash DISEASE ).
.
PMHx:
.
- hypothyroidism DISEASE
- osteoporosis DISEASE
- HTN DISEASE
- HLD
- hiatal hernia DISEASE and GERD DISEASE
- AAA DISEASE s/p repair [**2132**] then [**2134**] with concurrent b/l fem-[**Doctor Last Name **]
bypasses with complicated post-op course
- h/o peritonitis DISEASE [**2134**]
- h/o SBO [**1-6**] abdominal adhesions in [**2132**]
- s/p cholecystectomy [**2138**]
- depression DISEASE [**2153**]
- Lung adenocarcinoma stage 1 s/p RLL wedge resection [**2154**] no
adjuvant tx multiple pulm ground glass opacities DISEASE with very
indolent growth pattern Admission Date: [**2189-2-18**] Discharge Date: [**2189-2-25**]


Service: CCU

HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female with a past medical history significant for coronary artery disease DISEASE congestive heart failure hypertension DISEASE
chronic autoimmune hemolytic anemia DISEASE and history of a
gastrointestinal bleed DISEASE who presented to the Emergency
Department at [**Hospital1 69**] at 8 A.M.
with epigastric pain DISEASE . The patient's pain DISEASE started at
approximately 7:30 A.M. on the day of admission after eating
breakfast. It was described as a burning sensation. The
patient took one sublingual nitroglycerin without effect.
The patient reportedly denied any shortness of breath DISEASE
nausea vomiting fevers chills DISEASE or headache DISEASE . The patient
had been off her aspirin and Plavix secondary to a
gastrointestinal bleed DISEASE in [**2188-12-26**] requiring
hospitalization at [**Hospital3 1196**].

Electrocardiogram obtained in the Emergency Department showed
upsloping ST segments and was initially interpreted as
J-point elevation. Subsequently at 1 P.M. the patient's
systolic blood pressures decreased to the 40s and repeat
electrocardiogram at that time revealed bigeminy DISEASE with ST
elevations of 5 mm in V2 through V4. Cardiology team was
consulted and the patient brought emergently to the
catheterization laboratory with systolic blood pressures in
the 80s.

In the catheterization laboratory the patient's blood
pressure was marginal with pressures between 70s and 80s
systolic and dopamine drip was started. Initial angiogram
showed significant left anterior descending obstruction.
Intra-aortic balloon pump was placed. The patient was then
electively intubated as oxygen saturations were decreasing
on non-rebreather mask. Arterial blood gas as that time was
a pH of 7.16 pCO2 of 51 and pO2 of 51.

PAST MEDICAL HISTORY:
1. Coronary artery disease status post left anterior
descending stent and percutaneous transluminal coronary
angioplasty to diagonal I and obtuse marginal I on [**2188-11-28**]
2. Congestive heart failure
3. Hypertension DISEASE
4. Chronic autoimmune hemolytic anemia DISEASE
5. History of a gastrointestinal bleed DISEASE recently discharged
from the hospital on [**2189-2-10**]

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS AT HOME: Enteric-coated aspirin 325 mg by mouth
once daily held since [**2-10**] Plavix 75 mg by mouth once
daily held since [**2-14**] Synthroid 25 mcg by mouth once
daily Zestril 5 mg by mouth once daily Lopressor 50 mg by
mouth twice a day folate 1 mg by mouth once daily Protonix
40 mg by mouth once daily Timoptic one drop to each eye once
daily Xalatan one drop to each eye once daily prednisone 30
mg by mouth once daily

PHYSICAL EXAMINATION: Vital signs: Temperature 98.8 blood
pressure 88/42 heart rate 122 respiratory rate 16 oxygen
saturation 100% on 50% FIO2. In general the patient is an
elderly white female sedated and intubated. Heart: Regular
rate and rhythm positive S1 and S2 no murmurs gallops or
rubs. Lungs: Bibasilar crackles. Abdomen: Soft
nontender nondistended normal active bowel sounds.
Extremities: No cyanosis clubbing DISEASE or edema DISEASE right groin PA
catheter and arterial line in place left groin intra-aortic
balloon pump in place.

LABORATORY DATA: White blood cells 14.2 hematocrit 31.8
platelets 283. Differential: Neutrophils 97% lymphs 3%.
Sodium 142 potassium 3.4 chloride 106 bicarbonate 24 BUN
23 creatinine 0.8 glucose 101. INR 1.1 PTT 20.6 PT 12.7.
CK at 10 A.M. on [**2-18**] of 46 at 2 P.M. 475 with an MB of
60 and an MB index of 12.6 and a troponin of 40.9.
Urinalysis was benign. Chest x-ray showed heart size within
normal limits a prominent pulmonary vasculature was noted
bilateral interstitial opacities DISEASE were noted.
Electrocardiogram at 8:47 A.M. showed sinus at 87 beats per
minute left axis deviation with left ventricular
hypertrophy DISEASE 1 to [**Street Address(2) 1766**] elevations in V1 upsloping ST
elevations in V2 and V3 no ST depressions or Qs.
Electrocardiogram at 1:05 P.M. with decreased blood pressure
showed bigeminy DISEASE at 96 beats per minute [**Street Address(2) 1755**] elevations in
V2 and V3 2 to [**Street Address(2) 2051**] elevations in V4 and V5 ST
depressions DISEASE in II III and AVF Q waves developed in V2
through V5 with loss of R DISEASE wave progression. Cardiac
catheterization from [**2189-2-18**] had the following
findings: Left dominant system with three vessel coronary
artery disease DISEASE the left main coronary artery was normal the
left anterior descending was totally occluded at the site of
the previously-placed proximal stent the ramus intermedius
branch had a long tubular 80% stenosis the left circumflex
artery had a 50% proximal stenosis the first obtuse marginal
branch was totally occluded and the second obtuse marginal
branch had a 70% origin stenosis the left posterior
descending artery had a mild luminal irregularity the right
coronary artery was a small non-dominant vessel and had an
80% proximal stenosis. Successful percutaneous transluminal
coronary angioplasty of the proximal left anterior descending
in-stent lesion DISEASE and successful percutaneous transluminal
coronary angioplasty and stenting of the ramus intermedius
branch. Hemodynamic measurements performed after the
coronary intervention with the patient intubated requiring
intravenous inotropic support with intra-aortic balloon pump
in the left femoral artery revealed elevated left-sided
filling pressures. The wedge pressure was 21 mm Hg. The
cardiac index was marginally decreased at 2.1. As above an
intra-aortic balloon pump was introduced into the left
femoral artery.

IMPRESSION: 82-year-old female with previous coronary artery disease DISEASE status post recent left anterior descending
stent Class II congestive heart failure hypertension DISEASE
history of recent gastrointestinal bleed DISEASE presents with acute
ST elevation anteroseptal and anterior wall myocardial
infarction DISEASE . Taken to the catheterization laboratory for
intervention and admitted to the Coronary Care Unit
intubated with an intra-aortic balloon pump in place as
well as on a dopamine drip secondary to hypotension DISEASE .

HOSPITAL COURSE BY SYSTEM:
1. Cardiac:
a. Ischemia: As above patient with proximal left anterior
descending stent in-stent re-stenosis DISEASE as well as significant
occlusion to the ramus intermedius status post intervention.
The patient was started on aspirin and Plavix
post-intervention. Peak CK was noted to be 71 to 85 which
was on [**2189-2-18**] which gradually trended down to a
value of 113 on the day of admission. In addition the
patient was started on an ACE inhibitor and beta blocker once
blood pressure could tolerate.

b. DISEASE Pump: As above patient noted to be in cardiogenic shock DISEASE
with increased wedge and decreased systolic blood pressure.
Intra-aortic balloon pump was placed in the catheterization
laboratory. The patient was also given lasix x 1 in the
catheterization laboratory for elevated wedge pressure and
diuresed well with this one-time dose. No additional lasix
doses were given on hospital day number one and greater
attention was paid to improving hemodynamics with pressor and
inotropic agents. The patient was initially transferred to
the Coronary Care Unit on a dopamine drip however was noted
to be markedly tachycardic to as high as 130s to 140s in
sinus rhythm. The decision was made to discontinue the
dopamine and start milrinone for inotropic effect and
Levophed for pressor support. The patient's blood pressure
was titrated to greater than 60 and the patient's heart rate
subsequently was better controlled in the 80s to 90s.
Subsequently with improved hemodynamics decision was made
to remove the intra-aortic balloon pump on hospital day
number three. In addition on the following day the
patient's milrinone and Levophed drips were discontinued as
the patient was maintaining adequate hemodynamics on her own.
Lastly a decision of whether the patient should be long-term
anticoagulated in light of her recent anterior wall event was
to be evaluated with an echocardiogram. Decision to
anticoagulate long-term will be weighed against the possible
risks in light of underlying gastrointestinal pathology and a
history of a recent gastrointestinal bleed DISEASE .

c. Rhythm: Patient noted to have a sinus tachycardia DISEASE on
arrival to the Coronary Care Unit on a dopamine drip.
Subsequently was switched to milrinone and Levophed drips.
The patient's sinus tachycardia DISEASE improved to normal sinus
rhythm with occasional episodes of nonsustained ventricular
tachycardia DISEASE which was thought secondary to reperfusion.

2. Pulmonary: Patient noted to be hypercarbia DISEASE and hypoxic
in the catheterization laboratory on a non-rebreather and
decision for intubation was made. The patient was maintained
on assist control on arrival to the Coronary Care Unit and
subsequently was weaned with successful extubation on
hospital day number three.

3. Hematology: Patient with a history of chronic anemia DISEASE
secondary to chronic autoimmune hemolytic DISEASE etiology
maintained on prednisone as an outpatient. In light of
recent events the patient was placed on stress dose steroids
through the intravenous which was subsequently changed to
oral prednisone. The patient received two to three units of
packed red blood cells while in the Coronary Care Unit
secondary to a slightly decreased hematocrit which was
thought secondary to her underlying chronic condition as well
as possibly secondary to her gastrointestinal bleed DISEASE in light
of some coffee-ground emesis DISEASE . The patient's hematocrit
remained relatively stable during her hospital stay with a
range of 28 to 33.

4. Gastrointestinal: As above patient with a history of a
gastrointestinal bleed DISEASE with one to two episodes of
coffee-ground emesis DISEASE while in the Coronary Care Unit. Coffee
grounds then cleared and the patient was maintained on
Protonix 40 mg intravenously twice a day. As above the
patient's hematocrit remained stable for the most part during
her hospital stay and she remained hemodynamically stable
and there was no need for Gastroenterology consult during
this hospital stay.

5. Renal: The patient's creatinine status post cardiac
catheterization remained at her baseline and there were no
acute renal issues while an inpatient at [**Hospital1 346**].

6. Fluids electrolytes and nutrition: Patient's
electrolytes were monitored closely with adequate repletion
especially in light of some ventricular ectopy DISEASE noted on
telemetry. Initially nothing by mouth secondary to
intubation and the patient was started on low-dose tube
feeds at 10 cc/hour ProMod with fiber. Upon extubation
tube feeds were discontinued and the patient was advanced to
an oral diet without complications.

This has been a dictation detailing the hospital events from
[**2189-2-18**] to [**2189-2-22**]. Addendum to follow
detailing the rest of the [**Hospital 228**] hospital course
including a list of discharge diagnoses discharge
medications and plan for discharge and follow up.




DR.[**Last Name (STitle) 2052**][**First Name3 (LF) 2053**] 12-462

Dictated By:[**Name8 (MD) 2054**]
MEDQUIST36

D: [**2189-2-25**] 01:50
T: [**2189-2-25**] 01:55
JOB#: [**Job Number 2055**]
Admission Date: [**2103-3-29**] Discharge Date: [**2103-4-10**]

Date of Birth: [**2069-12-2**] Sex: M

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Chest pain DISEASE and shortness of breath DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 2026**] is a 33 year old male who was transferred to [**Hospital1 18**]-ED
on [**3-29**] after developing chest pain DISEASE and shortness of breath DISEASE a
code blue was called while on [**Hospital Ward Name **] for out-patient CT
scan. He is well known to the surgical service he has a past
medical history significant for sigmoid diverticulitis DISEASE s/p
laparoscopic sigmoid colectomy. CT scan of chest demonstrated
bilateral pulmonary emboli he was oxygenating well on nasal
cannula an intravenous Heparin drip was started and he was
transferred to the ICU for close monitoring.

Past Medical History:
Past Surgical History:

Diverticulitis DISEASE
Post-operative abdominal collection

Past Surgical History:

[**2-28**] Laparoscopic sigmoid colectomy c/b anastomotic leak s/p
[**Doctor Last Name 3379**] procedure
Umbilical hernia DISEASE repair

Social History:
Smokes half a pack a day of tobacco. Alcohol rarely. No IV drug
use


Family History:
HTN DISEASE and DM

Physical Exam:
Upon admission:

98.2 102 137/89 19 98% room air

Gen: No active distress
Head/Eyes: Pupils equal and reactive to light extraocular
movements intact
ENT: Oropharynx clear no jugular venous distention
Chest: Clear to auscultation bilaterally
CV: Regular rate tachycardic
Abd: Soft non-distended Admission Date: [**2119-5-18**] Discharge Date: [**2119-5-27**]

Date of Birth: [**2050-10-17**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Codeine / Heparin Agents / Vancomycin

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Tx for hypotension/ sepsis DISEASE

Major Surgical or Invasive Procedure:
Transesophageal echocardiogram


History of Present Illness:
Pt is a 68 yo male with DM HTN deep brain stimulator who is
being transferred from the floor from hypotension DISEASE . Pt says that
he has been having fevers DISEASE off and on for 5 weeks. Max temp
reached 104. No weight loss DISEASE night sweats with this but pt does
endorses rigors/chills. He states that some nights he would have
fever DISEASE and sometimes his temperature would be 98.5 ( fevers DISEASE
generally occured at night). Pt did not go to his [**First Name3 (LF) 3390**] until this
past Tuesday. Blood cultures were drawn and grew out GPC in
clusters and pt was told to come to the ED. In the ED lactate
was 4.7 (attributed to rigors DISEASE as lactate was lower previously)
but patient did not meet strict criteria for sepsis DISEASE then and was
admitted to the floor and started on vancomycin.

Past Medical History:
1. DM 2 x 11 years
2. Essential tremor DISEASE followed by Dr [**Last Name (STitle) **] w/ DBS placed in [**2117**]

3. HTN DISEASE
4. melanoma DISEASE of ear 15 years ago
5. h/o falls admitted in [**2115**]
6. hypertTG leading to pancreatitis DISEASE in [**2107**]
7. ETOH hepatitis DISEASE
8. s/p CCY in [**2106**]
9. h/o peripheral neruopathy DISEASE
10. hx of CHF DISEASE
11. depression/anxiety DISEASE

Social History:
former physics instructor at [**University/College **]. Nonmarried no children. Lives
with sister in [**Name (NI) 745**]. No smoking. former heavy EtOH none now.


Family History:
Mother died of pancreatitis DISEASE . Sister died of pancreatic cancerAdmission Date: [**2115-11-14**] Discharge Date: [**2115-11-16**]

Date of Birth: [**2065-8-12**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Neosporin Scar Solution / adhesive bandage

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
hyperglycemia DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms. [**Known lastname 3401**] is a 50 y.o. woman with IDDM DISEASE c/b retinopathy DISEASE and
proteinuria DISEASE on insulin pump (followed at [**Last Name (un) **] by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 174**]) p/w hyperglycemia DISEASE in setting of emesis DISEASE and diarrhea DISEASE x1D.
Per pt she felt hyperglycemic at 5AM whe she noticed she was
urinating more frequently. At that time her FS in 300s (despite
being within normal limits yesterday normally 100s-120s):
subsequently 390 at 5am 400s after breakfast self-bolused
insulin and continued to be in 400 all day when she decided to
visit her PCP. [**Name10 (NameIs) **] reports nonbloody emesis DISEASE and nonbloody loose
stools throughout the day and reports feeling dehydrated. Pt's
last meal was at 9pm yesterday. Denies fevers/chills current
nausea DISEASE or abdominal pain DISEASE or myalgias DISEASE . Reports polyuria DISEASE but no
pyuria/hematuria/dysuria. Denies any chest pain/pressure chest
palpiations radiating pain DISEASE SOB pleuritic pain DISEASE . Denies
episodes of diaphoresis DISEASE . No recent sick contacts unusual diet
or recent travel. No recent changes in insulin or medications.
No recent antibiotic use.

In the ED initial VS T 100.4 HR 102 BP 111/42 RR 18 O2 99%
RA DISEASE . FS in triage was 452. Labs notable for lactate initially
4.1 WBC 18 BS 406 Admission Date: [**2154-4-22**] Discharge Date: [**2154-4-27**]

Date of Birth: [**2099-4-13**] Sex: M

Service: MEDICINE/[**Hospital1 212**]

HISTORY OF THE PRESENT ILLNESS: The patient is a 55-year-old
male with a history of end-stage renal disease DISEASE on
hemodialysis QMWF hepatitis C hypertension DISEASE
and type 2 diabetes DISEASE who was recently admitted to
the [**Hospital6 256**] in [**2154-2-16**]
with a question of cellulitis DISEASE versus an allergy DISEASE related to
his newly revised AV fistula DISEASE .

Recently the patient had begun to feel slightly out of the
ordinary about a week prior to presentation with some fatigue DISEASE
and lethargy DISEASE initially without any cough fever DISEASE or chills DISEASE .
Subsequently the patient developed some back and chest
soreness with achiness in the right chest with radiation to
the back. The patient did not go to his scheduled
hemodialysis on Friday because he did not feel well.
Instead he went to the [**Hospital3 **] Emergency Department
where he had a CT and chest x-ray where he was diagnosed with
osteoarthritis DISEASE and discharged.

The patient then went to hemodialysis the subsequent day. He
had a temperature of 102 that night. Again the patient
presented to the [**Hospital3 **] Emergency Room where he had a
chest x-ray showing pneumonia DISEASE . At that point the patient
preferred admission to the [**Hospital6 2018**] and presented to the Emergency Room on the same night.

At this time the initial read of his chest x-ray showed no
evidence of pneumonia DISEASE and the patient was sent home with the
diagnosis of costochondritis. Since this time which was on
[**2154-4-21**] the patient has had increasing lethargy DISEASE and
awoke confused and febrile DISEASE to 102 at which time again he was
brought back to [**Hospital6 256**].

PAST MEDICAL HISTORY:
1. Type 2 diabetes DISEASE for the past 21 years complicated by
retinopathy nephropathy DISEASE .
2. Hypertension.
3. End-stage renal disease DISEASE on hemodialysis since [**2153-9-16**]. AV fistula placed at outside hospital with
subsequent revisions times two.
4. History of C. difficile colitis DISEASE .
5. Diverticulosis.
6. Status post cholecystectomy.
7. Hepatitis C.
8. History of questionable CHF DISEASE likely secondary to volume
overload DISEASE from ineffective dialysis.
9. Cardiovascular: Echocardiogram in [**2154-1-16**] was a
limited study EF greater than 55% mild symmetric LVH DISEASE . No
known wall motion abnormalities DISEASE or valvular disease DISEASE .
10. Parathyroid adenoma DISEASE in left lower pole of thyroid.

MEDICATIONS AT THE TIME OF ADMISSION:
1. Ecotrin 325 mg p.o. q.d.
2. Insulin NPH 100 units per ml 35 units in the morning
15-20 units subcutaneously every evening.
3. Iron 325 mg p.o. q.d.
4. Lipitor 40 mg p.o. q.d.
5. Losartan 100 mg p.o. q.d.
6. Metoprolol 150 mg b.i.d.
7. Nephrocaps one p.o. q.d.
8. Norvasc 5 mg p.o. q.d.
9. Prilosec 20 mg p.o. q.d.
10. Renagel 800 mg p.o. t.i.d.

ALLERGIES: Cipro which causes mouth swelling.

SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **]
works as the [**State 350**] State Lottery however has not
been working recently. Denied any history of tobacco
alcohol or IV drug use.

PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
101.8 pulse 97 blood pressure 133/77 respirations 22
pulse oximetry 66% on room air increased to 93% on a 50%
face mask. General: Diaphoretic lethargic easily
arousable. HEENT: Anicteric. Pupils were equal and
reactive to light. Mucous membranes dry DISEASE . Neck: No
lymphadenopathy DISEASE JVD to 5 cm. Cardiovascular: Regular rate
and rhythm normal S1 S2 II/VI systolic murmur at the base.
Chest: Left mainly clear to auscultation except for slight
crackles at the base right with decreased breath sounds DISEASE half
way up with E/A changes. Abdomen: Soft nontender
nondistended positive bowel sounds no hepatosplenomegaly DISEASE .
No spider angiomata. Extremities: Warm no edema DISEASE right big
toe with 1 cm ellipsoid area of granulation tissue. No
fluctuants.

LABORATORY DATA AT THE TIME OF ADMISSION: White blood cell
count 9.5 hematocrit 34.9 platelets 254000. Differential:
Neutrophils 84.7% bands 0% lymphocytes 9.9% monocytes
4.9% eosinophils 0.1% basophils 0.3%.

Sodium 136 potassium 4.9 chloride 89 bicarbonate 28 BUN
49 creatinine 8.9 glucose 110. Calcium 10.5 magnesium
2.0 phosphorus 10.4.

Chest x-ray: Rapid interval development of diffuse
right-sided consolidation with tracheal shifting concerning
for collapse or plugging also with left upper lobe
infiltrates.

EKG: Increased T waves in inferior leads in V6 ST slightly
increased in lead V1.

HOSPITAL COURSE: 1. PULMONARY: The patient initially was
admitted to the Medical Intensive Care Unit given his
profound hypoxia DISEASE with a saturation of 66% on room air and his
chest x-ray which showed rapid development within one day of
what was initially read as a small questionable left lower
lobe infiltrate on [**2154-4-21**] and a chest x-ray on [**2154-4-22**] with diffuse right-sided consolidation as well as
left upper lobe infiltrate.

The patient was started on ceftriaxone and azithromycin. He
persistently had a dry cough DISEASE without any sputum. The patient
was initially on a 50% face mask at which time he desaturated
to the high 90s. He was changed to a nonrebreather.
Subsequently on nonrebreather he had an ABG of 7.42 41 77.

The patient was then weaned off oxygen from face mask to
nasal cannula and had a requirement of approximately 5-6
liters of oxygen. At this time he was transferred to the
medical floor where he was rapidly weaned to a saturation of
92% on room air. The patient was continued on a total of a
five day course of azithromycin as well as a five day course
of IV ceftriaxone which was then changed to cefpodoxime/
proxetil at 400 mg p.o. q.d. for an additional nine days to
complete a total of a 14 day course.

The patient had a repeat chest x-ray on [**2154-4-25**] that
showed complete resolution of all of his prior infiltrates.
The patient also had significant improvement in his lung
examination.

2. HYPERTENSION: The patient was maintained on his home
dose antihypertensive regimen with some initial holding of
his Lopressor in the Intensive Care Unit which was
subsequently restarted on the floor secondary to his elevated
blood pressures.

3. RENAL FAILURE: The patient was continued on his usual
regimen of hemodialysis. Given his hyperphosphatemia DISEASE the
patient was increased from 800 mg of Sevelamer p.o. t.i.d.
with meals to 1600 mg p.o. t.i.d. with meals.

4. RIGHT FOOT ULCER: Initially this was stable with no
signs of fluctuants or infection DISEASE . The patient was seen by
the Podiatry Service and according to Podiatry
recommendations the patient was treated with b.i.d. to t.i.d.
wet-to-dry dressing changes as well as antibiotic ointment
intermittently. The patient had his wounds debrided by his
attending physician on one to two occasions. The patient
continued to have subsequent limitation in his mobility
secondary to deconditioning as well as his right foot ulcer DISEASE .

The patient was seen by the Physical Therapy Service and
recommendations for transfer to a [**Hospital 3058**] rehabilitation
facility were made.

5. DIABETES MELLITUS: The patient was continued on his home
dose antidiabetic regimen with NPH and sliding scale insulin
with good glycemic control.

6. DISPOSITION: The patient continued to have improvement
from his initial pneumoniaAdmission Date: [**2154-6-2**] Discharge Date: [**2154-6-14**]

Date of Birth: [**2099-4-13**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 55 year-old man
with a history of diabetes/end stage renal disease DISEASE on
hemodialysis on the renal transplant list who presents with
fever DISEASE and cough DISEASE . The patient was in his usual state of
health until the day of admission when he noticed increasing
productive cough DISEASE increasing shortness of breath DISEASE and some
pleuritic chest pain DISEASE . He denies nausea vomiting diarrhea DISEASE
substernal chest pain abdominal pain DISEASE . He did have some
diarrhea DISEASE but no melena DISEASE or hematochezia DISEASE . He denies dysuria DISEASE
or hematuria DISEASE . Of note the patient also noticed right lower
extremity edema DISEASE for the two days prior to admission. He
reports increasing fatigue DISEASE . He denies headache DISEASE vision
changes nuchal rigidity DISEASE . The patient had a recent admission
on [**4-18**] with pneumonia DISEASE treated with Ceftriaxone and
Azithromycin and then oral Cefpodoxime on discharge.

PAST MEDICAL HISTORY:
1. Diabetes mellitus DISEASE type 2.
2. Hypertension.
3. Hypercholesterolemia.
4. End stage renal disease DISEASE on hemodialysis preparing for
transplant.
5. HCV.
6. Ischemic right foot ulcer DISEASE status post graft [**5-15**]. [**Doctor Last Name **] to
the posterior tibial.
7. Diverticulosis.
8. C-difficile [**11-16**].
9. Laparoscopic cholecystectomy.
10. AV fistula DISEASE .
11. Hyperparathyroidism DISEASE

ALLERGIES: Ciprofloxacin causes mouth swelling DISEASE Levo - rigors DISEASE

MEDICATIONS ON ADMISSION:
1. Metoprolol.
2. Losartan.
3. Atorvastatin.
4. Protonix.
5. Nephrocaps.
6. Tylenol.
7. Lipitor.
8. Aspirin.
9. Ibuprofen.
10. Amlodipine.
11. Sevelamer.
12. Vancomycin.
13. Ceftriaxone.

PHYSICAL EXAMINATION: Temperature 99.7 heart rate 94 blood
pressure 160/88 respiratory rate 24 sating 82% on room air
90% on a nonrebreather. In general the patient was
somnolent but arousable. HEENT pupils are equal round and
reactive to light. Extraocular movements DISEASE intact. Large
conjunctival hemorrhage DISEASE . Oropharynx is dry. Cardiovascular
holosystolic murmur DISEASE . Regular rate and rhythm. Lungs
decreased breath sounds to the left base. Abdomen positive
bowel sounds soft nontender nondistended. Extremities
left fistula thrill right lower extremity edema. Right toe
necrotic DISEASE with eschar DISEASE . No evidence of cellulitis DISEASE or pus.

LABORATORIES ON ADMISSION: White blood cell count 12.2
hematocrit 39 platelets 293 83% neutrophils no bands 12
lymphocytes 8.5 monocytes 1.9 eosinophils 4 basophils.
Chest x-ray demonstrated a right lower lobe infiltrate.
Electrocardiogram sinus at 62 normal axis normal intervals
peaked Ts in V2 left ventricular hypertrophy flat T wave
laterally no ST changes [**2154-5-10**]. No disease on
catheterization per report. No findings in computer. [**4-17**]
echocardiogram EF 60% trace MR trace AI. [**5-15**] AK popliteal
to posterior tibial.

HOSPITAL COURSE: 1. Renal: The patient was continued on
dialysis with management of volume status by the renal
consult team.

2. Right toe ischemia DISEASE : Vascular surgery was consulted
imaged the right lower extremity. Once the patient's other
issues (see below) are resolved the patient was taken for a
right great toe amputation by Dr. [**Last Name (STitle) **]. He was treated
with perioperative broad spectrum antibiotics and will be
discharged to physical therapy rehab.

3. Pulmonary: The patient was found to have a pneumonia DISEASE in
the right lower lobe. He was monitored in the Intensive Care
Unit for his hypoxemia DISEASE . He was intubated on [**6-4**] for hypoxic
respiratory failure DISEASE . He was treated with Ceptaz Vancomycin
and Azithromycin which was switched to Zosyn Azithromycin
and Vancomycin until [**6-6**] when his regimen was switched to
Vancomycin and Ceftriaxone until [**6-7**] when Flagyl was added.
At that time he required Dopamine for a drop in systolic
blood pressure to the 80s after being given Levofloxacin. He
was intubated approximately two days and then had an episode
of hypertension DISEASE to 240 and chest pain DISEASE . He ruled out for
myocardial infarction DISEASE and was started on antihypertensives.
On [**6-5**] the patient underwent a bronchoscopy with BAL
demonstrating no gross findings and 2Admission Date: [**2154-7-16**] Discharge Date: [**2154-7-17**]

Date of Birth: [**2099-4-13**] Sex: M

Service: [**Location (un) 259**]

HISTORY OF PRESENT ILLNESS: Fifty-five year old with male
with end-stage renal disease DISEASE who is hemodialysis dependent
who at dialysis session aborted midway on [**Last Name (LF) 2974**] [**2154-7-12**] because he developed chest pain DISEASE midway through dialysis.
Per his wife he has had very frequent episodes of chest pain DISEASE
more than 10 during dialysis since he was started on
hemodialysis in [**2153-8-16**]. He went to a hospital in
[**Hospital1 392**] where he was started on nitrodrip. His chest pain DISEASE
resolved and has not returned since and he went home the
next day. His wife noted that the workup for his chest pain DISEASE
has been negative in the past including a cardiac
catheterization done in [**2153-9-16**] which showed normal
coronary arteries.

Since the night prior to admission he has had cough DISEASE . No
fevers DISEASE no chills DISEASE . He missed dialysis today [**7-15**]
because he was sent to the Emergency Department from home
shortly before he was scheduled for his 5 pm dialysis. He
denies any changes in his diet or noncompliance with dietary
restrictions. He has been unable to lie flat this past day
due to shortness of breath DISEASE . This is new compared with his
baseline. He does not complain of shortness of breath DISEASE at
rest currently and says that he is able to work but that
his exercise tolerance is markedly decreased compared with
his baseline. In the Emergency Department his oxygen
saturation on room air is 80% so he was begun on a
nonrebreather mask.

PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus DISEASE for the past 21 years complicated
by retinopathy DISEASE and nephropathy DISEASE .
2. Hypertension DISEASE .
3. End-stage renal disease DISEASE on hemodialysis since [**2153-6-16**]. The patient has an A-V fistula DISEASE placed at outside
hospital with subsequent revisions on two occasions. The
patient undergoes dialysis Monday Wednesday [**Year (4 digits) 2974**] at South
Suburban in [**Hospital1 392**].
4. History of Clostridium difficile colitis DISEASE .
5. Diverticulosis.
6. Status post cholecystectomy.
7. Hepatitis C.
8. History of questionable congestive heart failure DISEASE likely
secondary to volume overload DISEASE from an infected dialysis.
9. Prior cardiovascular evaluation echocardiogram in [**2154-1-16**] was a limited study and showed an ejection fraction
of greater than 55% mild symmetric left ventricular
hypertrophy DISEASE no known wall motion abnormalities DISEASE or valvular
disease.
10. Parathyroid adenoma DISEASE in the left lower pole of the
thyroid. He is scheduled for surgery on [**2154-8-2**].
11. Status post right great toe amputation [**2154-6-12**].
12. Status post right popliteal to posterior tibial artery
bypass [**2154-5-15**].
13. History of multiple pneumonias DISEASE and recurrent pneumonia DISEASE .
14. Patient is scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Vascular
Surgery for a right carotid artery pseudoaneurysm DISEASE repair.

MEDICATIONS ON ADMISSION:
1. Hydralazine 50 mg qid.
2. Clonidine patch 0.2 mg/hour one patch q Monday.
3. Combivent inhaler two puffs qid.
4. Cozaar 100 mg po q day.
5. Heparin IV with dialysis.
6. Lopressor 150 mg po bid.
7. Multivitamin tablet one tablet po q day.
8. Norvasc 10 mg one tablet po q day.
9. Percocet 1-2 tablets po q4h prn pain DISEASE .
10. Protonix 40 mg po q day.
11. Zocor 20 mg po bid.
12. Folic acid one tablet po q day.
13. Renagel two tablets po tid with meals.
14. ASA 325 mg po q day.
15. Insulin NPH 7 units subcutaneous q am.

ALLERGIES: Ciprofloxacin causes mouth swelling but no
difficulty breathing.

FAMILY HISTORY: Mother and father have a history of
diabetes DISEASE .

SOCIAL HISTORY: Patient used to work for the State Lottery
System currently is unemployed. Lives in [**Location 38**] with his
wife and two children ages 17 and 20. He has never smoked.
Denies alcohol use.

REVIEW OF SYSTEMS: Patient notes chronic lower extremity
edema DISEASE right side greater than left side since his surgery
[**2154-6-12**]. Patient reports that he is reasonably
ambulatory at baseline.

PHYSICAL EXAMINATION: Temperature 96.9 blood pressure
186/67 respiratory rate 28 O2 saturation 94% on
nonrebreather. General: Please middle-aged man appearing
slightly tachypneic DISEASE in no acute distress. HEENT: Pupils are
equal round and reactive to light. Oropharynx with moist
mucosal membranes no erythema DISEASE and no lesions. Neck: 2 cm
pulsatile mobile mass in the right mid cervical area supple
no lymphadenopathy DISEASE . Chest: Breath sounds dull to half-way
up the posterior lung fields bilaterally with crackles at the
top of half-way up the lung fields also crackles in the
right middle lobe area upper lobes are clear to
auscultation. Heart: Regular rate and rhythm normal S1
S2 no murmurs rubs or gallops. Abdomen is soft
nontender nondistended positive bowel sounds. Extremities:
2Admission Date: [**2154-9-2**] Discharge Date: [**2154-9-5**]

Date of Birth: [**2099-4-13**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 55 year old
male with a history of end state renal disease DISEASE who was
admitted from [**Hospital6 33**] on [**2154-8-31**] with
acute shortness of breath chest pain DISEASE and hypoxia DISEASE . He was
saturating 70% on room air and was put on 100%
non-rebreather and was transferred to [**Hospital1 190**] for further management.

On arrival to [**Hospital1 69**] oxygen
saturation was 40% on 100% non-rebreather. The patient then
went into cardiac and respiratory arrest DISEASE with ventricular DISEASE
tachycardia DISEASE . He underwent defibrillation three times
received amiodarone and was intubated and transferred to the
Medical Intensive Care Unit.

Potassium was 6.3 on admission and EKG revealed peaked T
waves. Chest x-ray showed florid pulmonary edema DISEASE . He was
initially placed on a Nitroglycerin drip given 4 mg of
morphine one ampule of calcium gluconate 10 units of
insulin intravenously with one ampule of D50 and Lasix 200 mg
intravenously.

The patient's wife reports that he does not comply with his
diet. His two past episodes of congestive heart failure DISEASE have
been secondary to dietary noncompliance and difficulty
adhering to his fluid restriction.

In the Intensive Care Unit the patient had troponin peaking
at 0.16 which was attributed to recent cardiac
defibrillation.

The Renal Service got involved and dialyzed about two to
three liters off on [**9-2**]. The patient spiked a fever DISEASE to
101.0 F. on [**9-2**] with a urinalysis with six to ten
white blood cells and moderate bacteria. Zosyn was started.
A chest x-ray was questionable for aspiration pneumonia DISEASE .

During his Medical Intensive Care Unit stay the patient was
transiently on Dopamine which was attributed to sedation and
hypotension DISEASE with propofol. The patient self-extubated
himself on [**9-3**] and has been stable from the hemodynamic
and respiratory standpoint.

PAST MEDICAL HISTORY:
1. End-stage renal disease DISEASE on hemodialysis. Dry weight of
65 kilograms. The patient has a left sided arteriovenous
graft.
2. Diabetes mellitus DISEASE complicated by nephropathy DISEASE and
retinopathy DISEASE .
3. Congestive heart failure DISEASE .
4. Cardiac catheterization in [**2153**] negative for coronary
artery disease DISEASE .
5. Hypertension DISEASE .
6. Echocardiogram in [**2154-6-16**] showing an ejection
fraction of 55% mild atrial fibrillation DISEASE .
7. Peripheral vascular disease DISEASE status post right first toe
amputation.
8. Hepatitis C.
9. History of recurrent pneumonia DISEASE .
10. Right popliteal tibial bypass one year ago.
11. Diverticulosis.
12. Hyperparathyroidism DISEASE .
13. Dyslipidemia DISEASE .

MEDICATIONS AT HOME:
1. Metoprolol 150 twice a day.
2. Folate 1 mg q. day.
3. Prilosec 20 mg q. day.
4. NPH 7 units q. a.m.
5. Enteric-coated aspirin 325 q. day.
6. Norvasc 10 mg q. day.
7. Lipitor 40 mg q. h.s.
8. Hydralazine 50 mg four times a day.
9. Losartan 100 mg q. day.
10. Nephrocaps one q. day.
11. Renagel 800 mg three times a day.
12. Trazodone 50 mg q. h.s.

MEDICATIONS ON TRANSFER TO THE MEDICAL INTENSIVE CARE UNIT:
[**Unit Number **]. Zosyn 2.25 mg intravenously three times a day.
2. Tylenol p.r.n.
3. Trazodone 50 mg q. h.s. p.r.n.
4. Metoprolol 25 mg p.o. twice a day.
5. Protonix 40 mg p.o. q. day.
6. Savelamer 800 mg p.o. three times a day.
7. Nephrocaps one q. day.
8. Lipitor 40 q. day.
9. Aspirin 325 mg q. day.
10. Regular insulin sliding scale.
11. Folate.

SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] tobacco no alcohol. Occasional cocaine use.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION: On transfer to the Medical Intensive
Care Unit revealed temperature maximum 101.8 F. temperature
current 99.5 F.Admission Date: Discharge Date: [**2155-6-13**]

Date of Birth: [**2099-4-13**] Sex: M

Service:


PROCEDURES PERFORMED: Cadaver kidney transplant.

ADMISSION DIAGNOSES:
1. Endstage renal disease DISEASE secondary to diabetes mellitus DISEASE .
2. Peripheral vascular disease DISEASE .


POSTOPERATIVE DIAGNOSES:
1. Endstage renal disease DISEASE secondary to diabetes mellitus DISEASE .
2. Peripheral vascular disease DISEASE .


HOSPITAL COURSE: Mr. [**Known lastname 3419**] is a 56-year-old male with
endstage renal disease DISEASE secondary to diabetes mellitus DISEASE who
after listing for cadaver kidney transplant an organ become
available. He was taken to the operating room on [**2155-2-24**]
where he underwent placement of a cadaver kidney in the left
iliac fossa. His posttransplant course was uncomplicated.
The kidney began making urine almost immediately after
implantation. He did not require dialysis in the
postoperative period. He was started with usual induction
immunosuppression which includes 3 doses of Thymoglobulin
followed by introduction of calcineurin inhibitors namely
tacrolimus when the renal function improved. He also
received steroid taper and CellCept. On postoperative day 2
he was started on a clear liquid diet which was advanced to
the rest of his hospital stay. His [**Location (un) 1661**]-[**Location (un) 1662**] drain and
Foley were removed on postoperative day 4 and on
postoperative day 5 he was certainly ready for discharge.
He achieved a satisfactory prograf levels. Was able to
demonstrate understanding and knowledge of his
immunosuppression regimen after teaching from the transplant
coordinators. He was discharged home on [**2155-2-28**] and he
will follow up with the transplant service in 1 week.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] [**MD Number(1) 3432**]

Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2155-6-13**] 08:48:39
T: [**2155-6-13**] 10:53:16
Job#: [**Job Number 3434**]
Admission Date: [**2163-2-28**] Discharge Date: [**2163-3-7**]

Date of Birth: [**2086-12-13**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamide Antibiotics) / Percocet / Lipitor / Zocor /
Levaquin

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fever DISEASE

Major Surgical or Invasive Procedure:
arterial line

History of Present Illness:
76 year old female with h/o hypothyoidism HTN/HLP AAA repair
in past with notable known lung adenoCA and new RLL lung mass
which has enlarged in size over the last 4 months being
followed by Dr. [**Last Name (STitle) **] in oncology was discharged yesterday
after admission for bronchoscopy c/b pneumothorax DISEASE for which a
pigtail was placed (removed at time of discharge). Tonight was
home noted to have increased cough DISEASE with rusty colored sputum
and fever DISEASE to 102. Also seemed to be more lethargic to family
members. FSG 97 for EMS. Sats low 90's on 3L nc.
.
ED Course: Initial Vitals/Trigger: 102 97/37 17 94% 6L nc.
Chest xray notable for possible increased patchy opacity DISEASE R lung.
Labs notable for WBC 16.7 (N 82.2) Na 128 Creat 2.1 lactate
0.9 Hct 29.2. UA wnl. Sputum blood and urine cultures sent.
She was given 3L IVF NS and started on empiric IV abx coverage
with cefepime 1g vancomycin 1g and levofloxacin 750mg IV. She
received benadryl for extremity erythema DISEASE and itching during
peri-administration with vancomycin - slowed rate of infusion as
well. She received tylenol for fever DISEASE 102 in the ED. IP fellow
was notified about re-presentation.
Admission Vitals: 90 91/25 12 93% 5L nc. Access: 18G x2.
Received 3L NS IVF.
.
On arrival to the ICU pt is sedated secondary to benadryl (per
daughter) but easily arousable. Daughter says that mental status
improved after IVF and abx administration in the ED with
increased somnolence DISEASE after IV benadryl administration. Daughter
and pt confirm the above story.
.
Review of systems:
(Admission Date: [**2100-9-3**] Discharge Date: [**2100-9-8**]

Date of Birth: [**2024-9-1**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
R face and arm weakness

Major Surgical or Invasive Procedure:
IV TPA

History of Present Illness:
The patient is a 76 year old primarily-Cantonese speaking
man with vascular risk factors who was in his usual state of
health until 8:30pm this evening. At that time while watching
TV he felt generally weak and unwell. He asked his wife to help
his to the bathroomAdmission Date: [**2112-12-8**] Discharge Date: [**2112-12-10**]


Service: MEDICINE

Allergies DISEASE :
Sulfonamides

Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
82 yo F with CAD CHF HTN DISEASE recent PE ([**10-17**]) who presents from
rehab with hypoxia DISEASE and SOB despite Abx treatment for PNA x 3
days. The patient was in rehab after being discharged from here
for PE. She was scheduled to be discharged on [**12-6**]Admission Date: [**2189-2-18**] Discharge Date: [**2189-2-26**]


Service: CCU

Please note that this interval dictation takes up on [**2189-2-23**] where the dictation of Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) **] previously
dictated left off.

ADDITIONAL HOSPITAL COURSE: The patient was transferred from
the Coronary Care Unit to the floor at approximately 3 A.M.
on [**2-23**] without event. At approximately 9 A.M. the
patient began to complain of shortness of breath DISEASE and was
found to be tachycardic to the 150s after walking a distance
to the bathroom. The patient's electrocardiogram
demonstrated sinus tachycardia DISEASE with ST elevations in Leads V2
and V3 otherwise the electrocardiogram was unchanged. On
examination the patient had a blood pressure of 146/60
pulse of 135 pulse oxygenation 98% on 2 liters was
diffusely wheezy DISEASE on respiratory examination and was markedly
diaphoretic without jugular venous distention DISEASE or edema DISEASE . The
patient was given several doses of intravenous Lopressor as
well as high-dose intravenous lasix. The pulse oxygenation
transiently fell to 88% on 5 liters face mask and an
arterial blood gas taken was 7.37/32/56. A chest x-ray
demonstrated increased congestive heart failure DISEASE and the
patient was given some nitro paste without effect and then
begun on nitroglycerin drip as well as additional lasix 80 mg
intravenous push.

The patient rapidly thereafter clinically improved with a
blood pressure falling from a high in the 170s/80s to 135/76
with a normalization of respiratory rate and a pulse
oxygenation of 92 to 95% on 6 liters as well as over a liter
of urine out ultimately and a clearing of previous wheezing DISEASE
on examination.

The patient was again cycled with cardiac enzymes which
revealed a troponin elevated greater than the measurable
range likely from the prior cardiac events that were
described in Dr.[**Name (NI) 2056**] dictation. However repeated
measurements of creatine kinase failed to demonstrate an
elevation in that enzyme and rather demonstrated a continued
trend down. The patient was begun on standing lasix
initially at 40 mg once daily which was then increased to 40
mg twice a day and then to 80 mg by mouth twice a day. The
thought being that the patient had been approximately 4
liters positive during this admission and that the
above-described events likely represented worsening
congestive heart failure/pulmonary edema DISEASE in the setting of
volume overload DISEASE . Additionally the patient's blood pressure
was better controlled with Captopril 12.5 mg by mouth three
times a day and the patient's Lopressor dose as well was
increased to 50 mg by mouth three times a day with good
effect on the patient's cardiac rate.

The patient's hematocrit continued to be stable for the
remainder of this admission. She had no further respiratory
difficulties and was seen by Physical Therapy who suggested
inpatient therapy to improve the patient's endurance.

The patient was sent for echocardiography which demonstrated
an ejection fraction between 20 and 25% with multiple wall
motion abnormalities as described. In discussion with the
Cardiology team the decision was made not to anticoagulate
the patient at this time given her recent history of
significant clinical gastrointestinal bleeding DISEASE . In
consultation with the patient's attending cardiologist
decision was made to discharge the patient to rehabilitation
on [**2189-2-25**].

Please note that during the sequence described for [**2-23**]
the patient's electrocardiogram appeared to show sinus
tachycardia DISEASE with the above-stated ST elevations in V2 and V3
which did resolve with the patient's tachycardia DISEASE .

ADDITIONAL DATA: The patient was sent for echocardiography
on [**2-24**] with the following findings: Symmetric left
ventricular hypertrophy DISEASE with extensive regional systolic
dysfunction consistent with coronary artery disease DISEASE
pulmonary artery systolic hypertension DISEASE moderate mitral regurgitation DISEASE mild aortic regurgitation DISEASE . The left
ventricular ejection fraction was estimated to be between 20
and 25%. Left ventricular wall motion was noted in detailed
report to have abnormalities in the basal anterior portion
which was hypokinetic mild mid-anterior which was akinetic DISEASE
basilar and anteroseptal which was akinetic DISEASE mid-anteroseptal
which was akinetic basal inferoseptal which was hypokinetic
mid-inferoseptal which was hypokinetic anterior apex which
was akinetic septal apex which was akinetic inferior apex
which was akinetic lateral apex which was akinetic DISEASE and apex
which was dyskinetic.

DISCHARGE MEDICATIONS: Lasix 80 mg by mouth twice a day
Captopril 12.5 mg by mouth three times a day Ambien 5 mg by
mouth daily at bedtime as needed Prevacid 30 mg by mouth
twice a day Timoptic 5% one drop to both eyes once daily
Xalatan one drop to both eyes once daily NPH four units
subcutaneously twice a day regular insulin sliding scale
folate 1 mg by mouth once daily Synthroid 25 mcg by mouth
once daily Plavix 75 mg by mouth once daily for 25 days (to
complete a one month course) Lopressor 50 mg by mouth three
times a day and hold for systolic blood pressure less than or
equal to 100 or pulse less than or equal to 60) aspirin 81
mg by mouth once daily levofloxacin 250 mg by mouth once
daily for five days (to complete a ten day course)
prednisone 50 mg by mouth once daily for four days then
prednisone 40 mg by mouth once daily for four days then
prednisone 30 mg by mouth once daily (this is the patient's
baseline prednisone dose for her autoimmune hemolytic DISEASE
anemia DISEASE ).

DISCHARGE DIAGNOSIS:
1. Status post myocardial infarction DISEASE
2. Congestive heart failure DISEASE
3. Hypertension DISEASE
4. Chronic autoimmune hemolytic anemia DISEASE
5. Gastrointestinal bleeding DISEASE

DISCHARGE PLAN: The patient will be discharged to
rehabilitation. She is to follow up with her primary care
physician and cardiologist within one week of discharge from
rehabilitation as well as with her primary
hematologist/oncologist or other physician for follow up of
chronic autoimmune hemolytic anemia DISEASE . The patient will be
continued on finger stick blood glucoses four times a day
with regular insulin sliding scale as described. It is
suggested that the patient's electrolytes be measured every
other day and repleted as necessary.

CONDITION ON DISCHARGE: Stable.




[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 2057**]

Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36

D: [**2189-2-25**] 02:31
T: [**2189-2-25**] 02:38
JOB#: [**Job Number 2059**]
Admission Date: [**2139-1-14**] Discharge Date: [**2139-1-22**]

Date of Birth: [**2059-5-5**] Sex: M

Service: SURGERY

Allergies DISEASE :
Lisinopril / Aspirin Enteric Coated

Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Abdominal Distention
Nausea DISEASE and Vomiting DISEASE

Major Surgical or Invasive Procedure:
[**1-14**]:
1. Lysis of single strand adhesion with derotation of a
volvulus DISEASE
2. Placement of a nasogastric tube

[**1-15**]: Second look laparotomy


History of Present Illness:
79M s/p repair of AAA [**1-31**] presents with abdominal distention DISEASE
nausea DISEASE and vomiting DISEASE .

Past Medical History:
CAD (s/p CABG)
HTN DISEASE
Admission Date: [**2140-8-19**] Discharge Date: [**2140-8-29**]

Date of Birth: [**2058-12-14**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Sulfa(Sulfonamide Antibiotics) / Zocor / aspirin

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypotension DISEASE

Major Surgical or Invasive Procedure:
[**2140-8-20**] OPERATIONS PERFORMED:

1. Infrarenal inferior vena cava DISEASE filter.
2. Coil embolization of branches of the left hypogastric artery.


History of Present Illness:
This is an 81-year-old gentleman with a past medical history of
CAD s/p MI MDS DISEASE on cycle 2 Vidaza anemia DISEASE severe COPD DISEASE baseline
home oxygen 2.5 L hypertension DISEASE hyperlipidemiaalso with
bladder cancer DISEASE status post TURBT and BCG treatment in [**2135**]
presenting with retroperitoneal bleed DISEASE . He presented to [**Location (un) 620**]
ED this afternoon with left sided abdominal pain DISEASE radiating to
his left thigh. He had previously been hospitalized there from
[**Date range (1) 3462**] for SOB and tachycardia DISEASE during which he was found to
have a PE and PNA and discharged to rehab on lovenox bridge to
coumadin and levfloxacin. CT at [**Location (un) 620**] showed active
extravasation on CTA abd/pelvis. HCT 23.9 received 1U PRBC and
10mg vitamin K and transferred to [**Hospital1 18**].
.
On arrival to the ED his VS were T 97.6 HR 122 bp 126/66 RR 20
100% ON 5L NC. HCT at 24.3 from 30.5 on discharge [**2140-8-9**] (after
transfusion). In ED Became hypotensive DISEASE to 59/44 with 1U PRBC
given 1 U FFP improving to 111/50 HR in 100s. ED EKG showed
sinus tachycardia DISEASE . Increasing pain DISEASE Admission Date: [**2187-4-6**] Discharge Date: [**2187-4-10**]

Date of Birth: [**2129-9-11**] Sex: F

Service: Medicine [**Hospital1 **] Firm

HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female with a history of obesity DISEASE severe obstructive sleep
apnea pulmonary hypertension DISEASE and diastolic congestive heart failure DISEASE who was recently discharged from the hospital on
[**3-23**] who returned for evaluation of persistent nausea DISEASE and
headache DISEASE that has been progressive since discharge.

She was admitted on [**3-19**] with hypoxia DISEASE and started on
[**Hospital1 **]-level positive airway pressure for obstructive sleep apnea DISEASE
in the hospital and discharged on [**3-23**] with home [**Hospital1 **]-level
positive airway pressure at night. She reported mild nausea DISEASE
before discharge but reports progressive symptoms over the
past two weeks not associated with eating. The patient
states her symptoms seem worse when she was off the [**Hospital1 **]-level
positive airway pressure machine. She was also complaining
of a headache DISEASE that is sometimes associated with nausea DISEASE but
not always. She denies any other urinary symptoms. She
denies gastrointestinal complaints DISEASE such as diarrhea DISEASE
abdominal pain DISEASE or constipation DISEASE . She denies any urinary
complaints such a dysuria DISEASE frequency or hematuria DISEASE . No chest
pain DISEASE . No increase in her lower extremity edema DISEASE . No increase
in her baseline shortness of breath DISEASE . She states her [**Hospital1 **]-level
positive airway pressure has not been fitting well and she
uses it less than three to four hours per night.

In the Emergency Room the patient was noted to be
hypertensive DISEASE with a systolic blood pressure of 214. She was
given 12 mg of Zofran 2 mg of Ativan and 4 mg of morphine.

PAST MEDICAL HISTORY:
1. Hodgkin's diseaseAdmission Date: [**2161-9-21**] Discharge Date: [**2161-9-24**]

Date of Birth: [**2128-11-1**] Sex: F

Service: [**Doctor Last Name **]

CHIEF COMPLAINT: High blood pressure.

HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old
African-American female with a history of chronic headaches DISEASE
obesity DISEASE and hypertension DISEASE who is admitted from her primary
care physician's office for a blood pressure of 190/140. She
reports intermittent headaches DISEASE for greater than one year
worsening in intensity over the last few weeks prior to
admission. The headaches DISEASE typically start in the right
occipital area move forward across the midline in the
frontal region. Extensive workup for headaches DISEASE including
head CT scan had been done all of which was unrevealing.

Over the week prior to admission she reported worsening of
her headache DISEASE general malaise constipation DISEASE and decreased
urination DISEASE during the day but increased at night. She had
recently stopped taking her atenolol which she began in
[**Month (only) 956**] of this year because her blood pressure was within
the normal range and she felt that stopping the medication
might make her feel better with regards to her general
malaise.

Upon seeing her primary care physician for [**Name Initial (PRE) **] routine office
visit she was found to have a blood pressure of 190/140 with
4Admission Date: [**2109-2-5**] Discharge Date: [**2109-2-18**]

Date of Birth: [**2024-7-25**] Sex: M

Service: SURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Gastric adenocarcinoma DISEASE .

Major Surgical or Invasive Procedure:
Subtotal gastrectomy with J-tube placement.

History of Present Illness:
This is an 84 year-old male with a relatively early staged
stomach cancer DISEASE in the distal region. Work-up has been negative
for metastatic disease. He does have some lymph node
enlargement in his mediastinum but those nodes were biopsy
negative and FDG negative. He presented this admission for
subtotal gastrectomy. He has known significant aortic stenosis DISEASE
without symptoms. The
valve area is quite tight at 0.8 sq cm but function is
preserved. Surgery was scheduled for [**2109-2-5**] with Dr.
[**Last Name (STitle) **].

Past Medical History:
PMH: Iron deficiency anemia DISEASE afib borderline diabetes H Pylori DISEASE
s/p treatment PUD emphysema peripheral vascular disease DISEASE

PSH DISEASE :
1. Appendectomy
2. Bilateral inguinal herniorrhaphy
3. Right total hip
4. Pacemaker insertion

Social History:
Born in [**Location (un) 86**] lived in the same house in [**Location (un) 3493**] with his
wife for 50 [**Name2 (NI) 1686**]. Three grown sons living in [**Name (NI) 745**] [**Name (NI) 3494**]
and [**Location (un) 3493**].
Wife not visiting because she has a cold.
Patient has housekeeper and landscaper at home.
Retired insurance broker.
He drinks occasionally.
30-pack-year history of smoking stopped years ago.


Family History:
Aneurysm DISEASE in mother and sister.
[**Name (NI) 3495**] disease in father and brother.
[**Name (NI) **] cancer DISEASE history.


Physical Exam:
Discharge Physical Exam:
VS: Temp 97.6F HR 60 BP 90/52 RR 18 SaO2 93% RA DISEASE
GEN: NAD AAOx3
RESP: CTAB no wheezing/rhonchi
CARD: RRR
ABD: Soft nontender nondistended normal bowel sounds
well-healing midline incision no erythema DISEASE or drainage J-tube
in place with no surrounding erythema DISEASE or drainage
EXT: Warm well perfused no peripheral edema DISEASE

Pertinent Results:
POST-OP DAY 1 LABS:
[**2109-2-6**] 06:35AM BLOOD Hct-30.3*
[**2109-2-6**] 06:35AM BLOOD Glucose-138* UreaN-27* Creat-1.1 Na-139
K-5.1 Cl-107 HCO3-24 AnGap-13
[**2109-2-6**] 06:35AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.5
.
DAY OF ICU TRANSFER LABS:
[**2109-2-10**] 06:19PM BLOOD WBC-5.1 RBC-2.72* Hgb-8.7* Hct-26.1*
MCV-96 MCH-32.0 MCHC-33.4 RDW-14.2 Plt Ct-103*
[**2109-2-10**] 06:19PM BLOOD Neuts-93* Bands-0 Lymphs-4* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2109-2-10**] 06:19PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2109-2-10**] 06:19PM BLOOD PT-11.4 PTT-27.6 INR(PT)-1.1
[**2109-2-10**] 06:19PM BLOOD Glucose-138* UreaN-23* Creat-0.9 Na-138
K-5.1 Cl-109* HCO3-20* AnGap-14
[**2109-2-10**] 06:19PM BLOOD CK(CPK)-78
[**2109-2-10**] 06:19PM BLOOD CK-MB-2 cTropnT-Admission Date: [**2139-10-22**] Discharge Date: [**2139-10-26**]

Date of Birth: [**2081-5-30**] Sex: F

Service: CARDIOTHORACIC SURGERY

HISTORY OF PRESENT ILLNESS: This is a 58 year old female
patient with known aortic stenosis DISEASE and aortic insufficiency DISEASE .
Recent echocardiogram revealed a decreased in left
ventricular function and she was referred to Dr. [**Last Name (STitle) **] for
an aortic valve replacement. On [**2139-10-1**] she underwent
cardiac catheterization which revealed normal coronary
arteries [**3-3**]Admission Date: [**2142-6-26**] Discharge Date: [**2142-7-6**]

Date of Birth: [**2081-5-30**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Shortness of Breath DISEASE

Major Surgical or Invasive Procedure:
tPA therapy

History of Present Illness:
Ms [**Known lastname 3501**] is a 61 yo W s/p St. [**Male First Name (un) 923**] aortic valve replacement for
severe AI by Dr. [**Last Name (STitle) 2230**] in [**2138**] who presented to her PCP five
days ago for annual checkup and for SOB. At that time she had
experienced months of increasing SOB notable over the past
several weeks. Echo was obtained which showed valve dysfunction DISEASE .
She was thus taken to cath where fluoro demonstrated a St. [**Male First Name (un) 923**]
aortic valve w/ one dysfunctional valve. She is transferred to
[**Hospital1 18**] for further care.

Past Medical History:
Aortic Insuffiency s/p St. [**Male First Name (un) 923**] Aortic Valve Replacement in [**2138**]
Asthma
Gout DISEASE
Gastroesophageal Reflux Disease DISEASE
s/p Lumbar Spinal Fusion
s/p Cholescystectomy
s/p Total Abdominal Hysterectomy

Social History:
Married and lives w/husband. Nonsmoker for 20y. No EtOH.
Disabled [**2-1**] back problems.

Family History:
Non-contributory

Physical Exam:
99.9 113/67 95 20 95RA
NADAdmission Date: [**2191-11-7**] Discharge Date: [**2191-11-25**]

Date of Birth: [**2155-5-17**] Sex: M

Service: MED

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Fevers cough DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Patient is a 36 yo male with a history of cerebral palsy DISEASE
epilepsy DISEASE aspiration aphasia DISEASE who was previously diagnosed with
right lower lobe pneumonia DISEASE on [**2191-10-5**] and completed a 10 day
course of levofloxacin. However he was brought to ED by group
home staff on [**2191-11-7**] with fevers DISEASE to 101 and productive cough DISEASE -
unclear if white or yellow phlegm DISEASE . The patient was febrile DISEASE in
the ED with a WBC of 18.8 and placed on Levo/Flagyl for
aspiration pneumonia DISEASE with CXR showing persistent cavitary RLL
pneumonia DISEASE with effusion. He was found to have a lung abscess DISEASE and
treated with IV Levo/Clinda.

Past Medical History:
cerebral palsy DISEASE
mental retardation
seizures DISEASE

Social History:
denies drugs EtOH tobacco
Lives in group home

Family History:
noncontributory


Physical Exam:
TcAdmission Date: [**2194-7-20**] Discharge Date: [**2194-7-22**]

Date of Birth: [**2155-5-17**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Fever seizure DISEASE .

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 39 year old male baseline nonverbal with
mental retardation cerebal palsy seizure disorder DISEASE history of
recurrent aspirations on a modified diet who presented to the ED
on [**7-20**] from his [**Hospital **] nursing home with seizure DISEASE x 2 on day of
presentation ( 7 pm 8:15 pm) with a fever DISEASE to 102. Status post
seizure DISEASE the patient was found to be hypoxic to 89% on RA DISEASE per
EMS report. His seizure DISEASE spontaneously resolved. The patient has
a history of multiple aspirations in the past. [**Name (NI) **] HCP
sister [**Name (NI) **] requested no central lines LP or femoral stick.

.
In the ED a CXR was obtained which showed no evidence of
infiltrate. His temperature in the ED was 103.8 for which he was
given tylenol. Given a concern for aspiration the patient was
given vanco 1 gm ceftriaxone 2 gm and flagyl. His pulse was
noted to be up to 146 BP 152/98 and he was sat'ing 100Admission Date: [**2175-8-29**] Discharge Date: [**2175-9-2**]

Date of Birth: [**2115-9-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
elective hernia DISEASE reapir

Major Surgical or Invasive Procedure:
right inguinal hernia DISEASE repair
ventral hernia DISEASE repair

History of Present Illness:
Patient is a 59 yo M with non ischemic dilated CMF with EF of
15-20% chronic A.fib DM2 DISEASE admitted for elective right inguinal
and ventral hernia DISEASE repain on [**8-29**] now transfered to the CCU for
hypotension DISEASE and ARF DISEASE . Patient tolerated the operation without
problems but noted to have BP ranging 75-84/50-60s (pre-op
105/60) post surgery. Patient was thought to be volume depleted
and given total 1.5 L fluid however his BP remained low. Patient
then noted to have low urine output to 5 cc/hr over last few
hours. Cr rising from 1.4 to 3.9. CXR shows cardiomegaly DISEASE
Admission Date: [**2189-3-17**] Discharge Date: [**2189-3-25**]


Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
woman with a history of coronary artery disease DISEASE with recent
CCU stay and autoimmune hemolytic anemia DISEASE who presented again
to the CCU after being admitted to the floor with a two-day
history of weakness increased shortness of breath DISEASE decreased

She had stent to the left anterior descending at an outside
hospital in [**2188-11-25**]. She then represented to [**Hospital6 1760**] on [**2189-2-18**] with her
anginal DISEASE equivalent ( epigastric pain DISEASE ) and was found to have ST
elevations on her electrocardiogram in leads V2-V5. She had
a complicated emergent catheterization. The catheterization
placed on Dopamine and intubated.

On catheterization the patient had in stent restenosis DISEASE of
the left anterior descending and she received percutaneous
transluminal coronary angioplasty. A lesion of the ramus
intermedius was stented as well. Intra-aortic balloon pump
was initiated at that time.

She had a four-day stay in the CCU when she was able to be
taken off the balloon pump and ventilatory support. She did
have an episode of acute hypoxia DISEASE after transfer to the floor
that improved with diuresis and nitrates. She was discharged
two weeks to this current admission to a nursing home.

On presentation to the Emergency Department the patient had a
heart rate of around 100 and systolic blood pressure in the
80-90s. Hematocrit was down to 24.5. Hematocrit on
discharge from her prior hospitalization was 33Admission Date: [**2176-7-2**] Discharge Date: [**2176-7-7**]

Date of Birth: [**2115-9-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3513**]
Chief Complaint:
Abdominal pain nausea and vomiting DISEASE .

Major Surgical or Invasive Procedure:
ERCP x 2.


History of Present Illness:
60 year-old male with history significant for severe nonischemic
hypertensive cardiomyopathy DISEASE (EF 20%) ICD placementdiabetes who
presents with abdominal pain nausea DISEASE and vomiting DISEASE since the
morning of admission. The patient states he ate breakfast at 9
am and approximately one hour later the pain DISEASE began and
continued to wax and wane throughout the day often reaching
[**11-6**]. The pain DISEASE was described as bandlike across his abdomen
without radiation to the back. No aggravating factors other than
eating. The pain DISEASE was alleviated with Morphine in the ED. The
patient has never had this type of pain DISEASE in the past. The patient
also complained of nausea DISEASE and vomiting DISEASE nonbilious/nonbloody.
The patient denied diarrhea melena DISEASE or hematochezia DISEASE . He denies
any recent changes in his medications recent travel recent
alcohol use history of gallstones DISEASE or symptoms of biliary colic DISEASE .

.
In the ED the patient received one liter NS morphine and a
dose of levofloxacin. The patient was admitted to the MICU.
.
In the MICU he was given NS at 150cc/hr. Antibiotics were not
continued. The biliary team saw the patient and recommended
ERCP. The procedure was deferred due to the patient's INR. The
patient's pain DISEASE was improved on transfer.

Past Medical History:
1. Diabetes mellitus DISEASE type 2 insulin dependent x 8 years
2. Cardiomyopathy DISEASE EF 20%
3. ICD placement
4. Elevated transaminases unknown etiology
5. Chronic atrial fibrillation DISEASE
6. Chronic renal failure DISEASE most recent creatinine 1.7
7. Umbilical hernia DISEASE repair [**8-/2175**]

Social History:
Lives with his wife has four grown children. Not currently
working on disability. Used to work in contruction. No tobacco
alcohol or illicits.

Family History:
No family history of heart disease DISEASE .

Physical Exam:
VS: T 98.2 HR 74 BP 125/71 RR 18 O2sat 98% RA DISEASE
GEN: Awake lying flat in bed NAD well developed
HEENT: Atraumatic DISEASE mild scleral icterus dry DISEASE mucosa
NECK: No JVD no LAD
CV: Soft [**3-5**] holosystolic murmur LSB irregular rhythm regular
rate
LUNGS: CTA B/L w/ good inspiratory effort
ABD: Mildly distended soft tender to palpation in upper
quadrants B/L and periumbilical. Negative [**Doctor Last Name **] sign no
rebound
EXT: Warm dry DISEASE no LE edema DISEASE
NEURO: AAOX3 follows commands answers questions appropriately
no focal deficits


Pertinent Results:
Labwork on admission:
[**2176-7-2**] 08:20PM WBC-9.3 RBC-4.95 HGB-14.6 HCT-40.5 MCV-82
MCH-29.5 MCHC-36.0* RDW-17.1*
[**2176-7-2**] 08:20PM NEUTS-58 BANDS-0 LYMPHS-32 MONOS-8 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2176-7-2**] 08:20PM PLT SMR-NORMAL PLT COUNT-149*
[**2176-7-2**] 08:20PM DIGOXIN-1.0
[**2176-7-2**] 08:20PM TRIGLYCER-165*
[**2176-7-2**] 08:20PM CK-MB-3 cTropnT-Admission Date: [**2176-12-28**] Discharge Date: [**2177-1-9**]

Date of Birth: [**2115-9-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Unasyn

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
rectal pain DISEASE


Major Surgical or Invasive Procedure:
central line placement
arthrocentesis
Incision and Drainage


History of Present Illness:
HPI: The patient is a 61 year old man with severe systolic CHF DISEASE
(EF 15-20%) HTN DM2 DISEASE who presents with rectal pain DISEASE . He states
that he has had 5 years of intermittent rectal pain DISEASE following a
colonscopy that diagnosed internal hemorrhoids DISEASE . He states that 5
days ago he had worsened rectal pain DISEASE that was worsened with
bowel movements DISEASE . He has seen small amounts of blood in his stool
over this time. He was seen by his PCP 2 days ago who prescribed
anusol. His pain DISEASE progressed and was referred to the ED yesterday
by his PCP.
.
In the ED his initial vitals were 98.8 85 144/83 18 94%RA. A
rectal exam showed L glutteal area/perirectal area Admission Date: [**2177-2-20**] Discharge Date: [**2177-2-25**]

Date of Birth: [**2115-9-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Unasyn

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hypotension DISEASE AMS

Major Surgical or Invasive Procedure:
None


History of Present Illness:
61y/o M w/ DM2 CHF DISEASE s/p ICD CRI and atrial fibrillation DISEASE
presenting today with altered mental status and hypotension DISEASE . The
patient was recently admitted to [**Hospital1 18**] in mid-[**Month (only) 1096**] with a
perirectal abscess DISEASE complicated by hypotension DISEASE and a MICU
admission. His course was further complicated by renal failure DISEASE
and a transaminitis DISEASE attributed to unasyn therapy. He was
discharged to a rehab facility on [**1-10**] and had recently left
that facility and returned home last week. According to his
wife he has been more sedated since discharge from the hospital
but otherwise has been doing relatively well at home. He
endorses chronic knee and LE pain DISEASE but denies any recent CP SOB
abdominal pain N/V DISEASE poor PO intake progressive weakness
paresthesias DISEASE HA melena DISEASE or BRBPR. He has noticed some
intermittant painless shaking in his hands that has occasionally
caused him to drop objects. He and his wife note good compliance
with his medications though she had held his coreg until
yesterday given slow HR at home. She feels that his altered
mental status can be directly attributed to the doses of
narcotics that he was discharge on as this was a new medication
for him. He has been eating well at home but did not take good
PO today despite receiving his regular dose of insulin.
.
Today he presented to a neurology appointment for further
evaluation of his hand shaking and there was noted to be
somnolent. His blood pressure was in the 80s systolic and he was
sent to the ED for further evaluation. There he was seen to be
bradycardic to the low 50s and somnolent. His glucose level was
33 and he received D50 and promptly awoke and was appropriate
per report. His bradycardia DISEASE was treated with atropine to which
his HR increased to the 70s and his relative hypotension DISEASE
(systolic Admission Date: [**2179-5-13**] Discharge Date: [**2179-5-23**]

Date of Birth: [**2115-9-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Unasyn

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
arm pain DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname 3517**] is a 63yo M w/hx of CHF DISEASE (EF 15-20%) s/p ICD
placement severe TR DM2 CKD (baseline Cr 1.3-1.8) afib on
coumadin elevated LFTs who presented to the ED with chest pain DISEASE
and L arm pain DISEASE . By report of wife and patient he has had bad
gout DISEASE over the past several weeks to months. Principally this
has been involving his right foot limiting his ability to walk.
In the past few days had increasing right arm pain DISEASE that patient
thought was also his gout DISEASE . Then starting about yesterday
patient had severe left arm pain DISEASE at the shoulder and the elbow.
This is ultimately what prompted him to come to the ED. ROS
notable for Admission Date: [**2180-4-25**] Discharge Date: [**2180-5-13**]

Date of Birth: [**2115-9-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Unasyn / Oxycodone

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
ICD firing CHF DISEASE exacerbation

Major Surgical or Invasive Procedure:
none


History of Present Illness:
64 year old male with PMHx of severe non-ischemic cardiomyopathy DISEASE
with EF 25% s/p ICD placement [**2175**] mild-mod MR/TR DM ICD
Afib DISEASE on coumadin gout hypothyroidism CKD p/w vtach and ICD
firing. Last Wednesday he returned from [**Country 3515**] which is where
he spends most of the year. He went to clinic to see Dr. [**First Name (STitle) 437**]
day prior to admission and appeared volume overloaded admitted
to running out of his prescriptions for at least 2 weeks. He
also had not been adhering to low salt diet. Amiodarone was
started in clinic for device discharges noted to have seven
episodes of VF DISEASE and VT DISEASE on device check yesterday. This morning
his ICD fired again and was advised to go to ED. He felt no sx
when his ICD fired butper report from wife he appeared to have
seizure DISEASE activity during this morning's shock DISEASE .
.
In the ED VS were 98.2 73 119/67 20 100%. He was noted to be
fluid overloaded on exam. Seen by EP in the ED who recommended
amiodarone loading for multiple episodes of VT/VF DISEASE .
.
On arrival to floor he complains of being tired. No chest
pain shortness of breath nausea vomiting DISEASE . His lower
extremities are swollen but he says this is stable. Also has
chronic orthopnea DISEASE .
.
On review of systems he denies any prior history of stroke DISEASE
TIA DISEASE deep venous thrombosis pulmonary embolism bleeding DISEASE at the
time of surgery myalgias DISEASE joint pains cough hemoptysis DISEASE black
stools or red stools. He denies recent fevers chills DISEASE or rigors.
He denies exertional buttock DISEASE or calf pain DISEASE . All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain DISEASE
dyspnea DISEASE on exertion paroxysmal nocturnal dyspnea orthopnea DISEASE
palpitations syncope DISEASE or presyncope DISEASE .


Past Medical History:
Nonischemic cardiomyopathy DISEASE LVEF 15-20%
ICD placement for primary prevention of sudden cardiac death DISEASE
Diabetes mellitus DISEASE type 2 insulin dependent
Gout DISEASE
Peripheral neuropathy DISEASE
Chronic atrial fibrillation DISEASE
Chronic kidney disease DISEASE
Elevated transaminases unknown etiology
Umbilical hernia DISEASE repair [**8-/2175**]
Gallstone pancreatitis DISEASE s/p ERCP ([**2176-6-28**])
Internal hemorrhoids
Hemoglobin C carrier


Social History:
The patient is originally from [**Country 3515**] currently living with his
wife. Returned to [**Location 3515**] this past fall but came back to US
after severe gout DISEASE flare of his foot. No smoking. He quit
alcohol use no IV drug use. He says his diet is generally
difficult because he
feels like any food he eats causes gout DISEASE flare
.


Family History:
No first-degree relatives with coronary artery disease DISEASE . His
mother had breast cancer DISEASE .
.


Physical Exam:
Admission:
VS: 99.9 112/69 76 20 97% RA DISEASE
GENERAL: obese M in NAD. Oriented x3. Mood affect appropriate.

HEENT: NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva were
pink no pallor or cyanosis DISEASE of the oral mucosa. No xanthalesma.

NECK: Supple with JVD to level of mandible.
CARDIAC: PMI located in 5th intercostal space midclavicular
line. RR normal S1 S2. 2/6 systolic murmur no r/g. No
thrills lifts. No S3 or S4.
LUNGS: No chest wall deformities scoliosis DISEASE or kyphosis DISEASE . Resp
were unlabored no accessory muscle use. crackles at bases
bilaterally wheezes or rhonchi.
ABDOMEN: Soft NTND. No HSM or tenderness DISEASE . Abd aorta not
enlarged by palpation. No abdominal bruits DISEASE .
EXTREMITIES: Admission Date: [**2180-5-23**] Discharge Date: [**2180-5-27**]

Date of Birth: [**2115-9-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Unasyn / Oxycodone

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
hypotension diarrhea DISEASE poor PO intake

Major Surgical or Invasive Procedure:
EJ placement
Swan placement
ICU stay

History of Present Illness:
Pt is a 64 yo male PMHx significant for non-ischemic
cardiomyopathy DISEASE with EF 25% s/p ICD placement [**2175**] (v paced)
mild-mod MR/TR DM ICD Afib DISEASE on coumadin gout hypothyroidism
CKD DISEASE p/w vtach and ICD firing recently admitted for ICD firing
CHF DISEASE w/ EF 20-25%% who presents from heart failure DISEASE clinic
w/hypotension. Pt has presumed Cdiff w/ continued diarrhea DISEASE
vomitting and decreased PO intake w/ associated dehydration DISEASE and
lethargy DISEASE at [**Hospital 100**] rehab facility d/c'ed from [**Hospital1 18**] Admission Date: [**2141-10-8**] Discharge Date: [**2141-10-17**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 3544**]
Chief Complaint:
hypoxia DISEASE

Major Surgical or Invasive Procedure:
PEG tube placement

History of Present Illness:
[**Age over 90 **] yo male with h/o Parkinson's dz spinal compression fractures DISEASE
and recent admission at [**Hospital1 **] from [**Date range (1) 3550**] for PNA who presents
from an OSH with PNA and stable hypoxia DISEASE . On [**10-3**] he was
admitted to OSH with worsening SOB. His sats were 89- 91% on a
NRB DISEASE and he was noted to be somnolent and in severe respiratory
distress. ABG was 7.30/60/88/29. CXR showed LLL infiltrate and
wbc was 11.9. He was intubated and treated for suspected PNA
with zosyn DISEASE and vancomycin at the OSH. He was ultimately
transferred to the [**Hospital1 **] for continued care per request of the
patient's wife.
.
In the MICU pt was continued on unasyn to complete 10 day
course of antibiotics for his aspiration pneumonia DISEASE . He was
witnessed to aspirate repeatedly leading to changes in mental
status and worsening hypoxia DISEASE . This prompted the placement of a
G-tube by GI on [**10-12**]. On [**10-13**] tube feeds were started per
nutrition recs. Pt's respiratory status remained tenuous but
stable and improved slowly every day. For decreased urine
output he received several IVF boluses. He was then transferred
to the medical [**Hospital1 **].


Past Medical History:
Osteoporosis DISEASE
Parkinson's Disease DISEASE
T11-12 compression fracture DISEASE
s/p laminectomy L4-5
left LE osteomyelitis DISEASE
liver disease-granulomatous disease DISEASE
LUE rotator tear
prostate CA-In DISEASE [**2126**] he had an orchiectomy for prostate cancer DISEASE

Social History:
The patient has a sixty-pack-year history of tobacco. He quit in
[**12/2098**]. He lives in a NH for the past 2 years. He is a retired
history professor. He reports no alcohol intake.


Family History:
Non-contributory


Physical Exam:
VS:Tc 96.2 HR 78 Bp 156/74 o2 sat 97% on 5 L NC RR 18
Gen: chronically ill appearing elderly male in NAD
HEENT: anicteric mouth with thick yellow respiratory secretions

NEck:supple no JVD
Pulm: rhonchorus breath sounds throughout no crackles
Cardio: difficult to hear heart sounds given diffuse rhonchi
RRR no murmurs or gallops
Abd: soft NT ND Admission Date: [**2141-12-10**] Discharge Date: [**2141-12-21**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Transfer to [**Hospital1 18**] per wife request with pneumonia DISEASE and UTI DISEASE


Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **] yo M with h/o Parkinson's aspiration pneumonia DISEASE who presented
to [**Hospital1 **] ER from NH with acute SOB. He initially had fever DISEASE
to 102 axillary and rigors DISEASE at his NH and was brought in by EMS.
EN route to [**Hospital1 **] his RR was elevated and he presented
there in respiratory distress febrile DISEASE to 103 and hypertensive DISEASE
to 160s/100. They treated him with nebs and lasix and his resp
status improved. CXR revealed LLL infiltrate and U/A was grossly
positive with Admission Date: [**2142-4-23**] Discharge Date: [**2142-5-3**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 3552**]
Chief Complaint:
SOB/altered mental status c/b hypercarbic respiratory failure DISEASE

Major Surgical or Invasive Procedure:
PICC
intubation


History of Present Illness:
As per MICU admission note patient is a [**Age over 90 **] yo male with h/o
parkinsons and 3 prior admissions with aspiration pneumonia DISEASE
requiring intubation on episode in [**9-8**] s/p [**Date Range 282**] placement who
presents from his NH with decreased oxygen saturation and
altered mental status. History is obtained per NH/hospital
records. Per the patient's wife the Pt desatted to 82% 2 nights
PTA returning to normal in the AM prior to admission. Pt
subsequently desatted later in the day. Pt was placed on 02 by
RT with good effect. [**Name (NI) 1094**] wife also reported low grade fevers DISEASE to
about 99.7 (baseline 97.0). Per the NH notes the patient has
not had a cough DISEASE but has been productive of thick clear sputum.
In addition he has also been more somnolent than normal
speaking less than usual. Of note the patient's wife reported
that though the most recent speech and swallow evaluation
recomended nectar thickened liquids and ground solids he has
been eating a regular diet.
.
In the ED the patient's vital signs were: T:99.4 HR:68 BP:161/83
RR:24 SaO2:100% on 3L. CXR showed LLL infiltrate and UA was
positive. The patient was given 1G Vanco 500mg Levoflox 500mg
flagyl sinemet x2 mirapex x1 and comptan x1.
.
Within an hour after arrival to the floor the patient was noted
to be somnolent and tired not responding to commands and
appearing lethargic. ABG was performed showing a pH 7.22 pCO2
104 pO2 146 HCO3 42. Given concerns for his hypercarbic DISEASE
respiratory failure DISEASE the patient was transferred to the MICU for
urgent intubation.
.
While in the MICU the patient was intubated for hypercarbic DISEASE
respiratory failure DISEASE and was been given vancomycin/zosyn to cover
both aspiration pneumonia DISEASE and urinary tract infection DISEASE . Mild
hypotension DISEASE with sedation.
.
ROS: Done on admission: Admission Date: [**2142-5-21**] Discharge Date: [**2142-5-29**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
mixed respiratory failure DISEASE


Major Surgical or Invasive Procedure:
intubation


History of Present Illness:
[**Age over 90 **]yo man with h/o Parkinson's disease DISEASE multiple prior admissions
for aspiration pneumonia DISEASE most recently [**2142-4-23**] who presents
again from [**Hospital 100**] Rehab after the staff there had Admission Date: [**2189-3-17**] Discharge Date: [**2189-3-27**]


Service: CCU

ADDENDUM:

DISCHARGE MEDICATIONS: 1. Enalapril 15 po b.i.d. 2. Lasix
40 po q.d. 3. Digoxin .125 po q.d. 4. Imdur 30 po q.d.
5. Prednisone 10 po q.d. 6. Tylenol prn. 7. Prevacid 30
po q.d. 8. Synthroid 250 micrograms po q day. 9. Aspirin
325 mg po q.d. 10. Plavix 75 po q.d. for life. 11. Folate
1 mg po q.d. 12. Timoptic .5 solution one drop each eye
q.d. 13. Zalatan .005% solution one drop each eye q.d. 14.
Lopressor 50 mg po b.i.d. 15. Ambien 5 po q.h.s. prn. 16.
NPH 4 units b.i.d. and then regular insulin sliding scale.
17. K-Dur 10 mg po q.d.

DISCHARGE INSTRUCTIONS: The patient should have potassium
followed in a couple of days and monitored closely and her
potassium dose adjusted as needed. She should have daily
weights and monitored for signs of congestive heart failure DISEASE .
The patient should follow up with Congestive Heart Failure DISEASE
Clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2067**] in one week. The phone number is
[**Medical Record Number 2068**]. She should also follow up with her primary care
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] in one week as well.






[**Last Name (LF) 1870**][**First Name3 (LF) **] 12.953

Dictated By:[**Name8 (MD) 2069**] MEDQUIST36

D: [**2189-3-27**] 13:26
T: [**2189-3-27**] 13:45
JOB#: [**Job Number 2070**]
1
1
1
R

Admission Date: [**2142-7-13**] Discharge Date: [**2142-7-19**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
-Unresponsive
-Mental status changes

Major Surgical or Invasive Procedure:
-Tracheostomy
-Femoral Line
-[**First Name3 (LF) 282**] tube change

History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **]-year-old gentleman with history of
[**Last Name (un) 3562**] Disease several aspiration events multiple
admissions for respiratory distress DISEASE who was sent from [**Hospital 100**]
rehab for evaluation after being found unresponsive at 3 PM. Per
report patient was found to open eyes but otherwise not
responding to verbal commands. ABG done at rehab showed marked
hypercarbia DISEASE (pCO2 100) and patient was referred urgently to the
ED.
.
In the Emergency Department patient was intubated for presumed
hypercarbic respiratory failure DISEASE . ABG was not done on admission.
CXR did not show any acute changes from ED visit 3 days prior
(he had presented to ED on [**2142-7-10**] with dyspnea DISEASE respiratory
status had returned to baseline CXR was unchanged and labs did
not reveal leukocytosis DISEASE ). He was given Vanc/Levo/Flagyl for
possible sepsis DISEASE albuterol/atrovent for bronchodilation and
methylprednisolone for Admission Date: [**2143-6-24**] Discharge Date: [**2143-6-26**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Hemoptysis DISEASE

Major Surgical or Invasive Procedure:
Bronchoscopy
[**First Name3 (LF) 282**] tube placement
Upper endoscopy

History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] year old gentleman resident of [**Hospital 100**] rehab
MACU with history of [**Last Name (un) **] Disease several aspiration
events leading to multiple admissions for respiratory distress DISEASE
and culminating in a tracheostomy ([**7-/2142**]) now presenting with
bleeding DISEASE around tracheostomy site which started earlier today.
Patient is accompanied by his wife who provides most of the
history. Patient was in his otherwise good state of health until
yesterdayt when nursing noted he had approximately 20-30 cc of
blood tinged sputum. Patient again had some small amounts of
bloody tinged secretions DISEASE this morning and then had about [**1-6**] of
a cup of bright red blood. Patient was given two doses of
racemic epinephrine via trach and was transferred to [**Hospital1 18**] for
futher evaluation.
Of note patient had a fall from the bed at MACU 1 week ago.
Patient was sleeping and fell in his sleepAdmission Date: [**2145-4-13**] Discharge Date: [**2145-4-20**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
s/p cardiac arrest DISEASE

Major Surgical or Invasive Procedure:
Mechanical ventilation
Placement of a right subclavian vein line
Bronchoscopy with bronchoalveolar lavage
Placement of an arterial line
Placement of dart catheter for pneumothorax DISEASE and removal
Trach exchange
PICC line placement
[**First Name3 (LF) 282**] replacement


History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **]yo M from [**Hospital 100**] Rehab baseline Alert and
Orientedx3 h/o Parkinson's s/p trach multiple DISEASE aspiration
events HTN DISEASE who was having BM today at Rehab became cyanotic
pulseless DISEASE and recieved chest compressions. He was never shocked
or given meds but had return of spontaneous circulation at
rehab. On arrival to the ED he was put on vent for poor resp
effort. Was making non-purposeful spont mvmts. EKG showed sinus
bradycardia DISEASE . Labs were unremarkable with a lactate of 2.0. Prior
to leaving the ED he is following commands communicating with
his wife by motioning. He is complaining of pain DISEASE in ribs. Also
in the ED CT head preliminarily read as not acute intracranial
process CXR with RUL and RML infiltrates c/w aspiration. He was
hemodynamically stable and cooling protocol was not initiated as
he was neurologically improving. No meds were given in ED except
for 1L NS.

On arrival to the ICU we was responding to commands and c/o
left sided rib pain DISEASE .

Review of systems: Pt unable to answer extensive ROS at this
time.


Past Medical History:
1. h/o aspiration PNA - Tx with levo unasyn vanco/zosyn in the
past
2. h/o aspiration s/p swallow eval with swallowing difficulty
s/p [**Hospital 282**] placement on [**10-9**] - pt continues to feed for pleasure
at Heb Reb
3. Parkinson's
4. Osteoporosis DISEASE
5. T11/12 compression fx
6. LLE osteomyelelitis as a child/Chronic osteomyelitis DISEASE
quiescent.
7. granulomatous liver disease DISEASE
8. LUE rotator cuff tear
9. Prostate cancer DISEASE s/p orchiectomy in [**2126**]
10. s/p laminectomy L4-5
11. Cataracts DISEASE s/p surgery
[**46**]. Glaucoma DISEASE
13. Hypertension DISEASE
14. Pt s/p recent tx for pseudomonas and aspiration PNA at heb
reb
15. s/p Trach with night ventilator support.
16. s/p wrist fx
17. chronic constipation DISEASE
18. Chronic abd pain- per Heb Reb notes

Social History:
The patient has a sixty-pack-year history of tobacco. He quit in
[**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is a
retired history professor. [**First Name (Titles) **] [**Last Name (Titles) **] no alcohol intake.

Family History:
Non-contributory

Physical Exam:
Vitals: 96.4 49 110/52 22 99% on MMV

General Appearance: Thin elderly male interactive. Answers
simple questions follows commands
Head Ears Nose Throat: Normocephalic Poor dentition
surgical left pupil
Cardiovascular: (S1: Normal) (S2: Normal). Bradycardic. No
MRG.
Respiratory / Chest: (Expansion: Symmetric) [**Month (only) **] BS at right
but o/w clear. ttp over left chest over ribs
Abdominal: Soft tender. No guarding or rebound. Bowel sounds
present Not Distended. Area around G tube erythematous no
purulence
Extremities: Right lower extremity edema DISEASE : Trace Left lower
extremity edema DISEASE : Trace


Pertinent Results:
Admission laboratories:
[**2145-4-13**] 03:00PM WBC-11.0 RBC-3.16* Hgb-9.8* Hct-30.6* MCV-97
Plt Ct-441*
[**2145-4-14**] 09:04AM Neuts-88.2* Lymphs-8.9* Monos-2.7 Eos-0.1
Baso-0.2
[**2145-4-13**] 03:00PM PT-13.4 PTT-26.0 INR(PT)-1.1
[**2145-4-13**] 07:17PM Glucose-115 UreaN-23 Creat-0.7 Na-140 DISEASE K-4.9
Cl-104 HCO3-26
[**2145-4-15**] 05:05AM ALT-1 AST-13 LD(LDH)-132 AlkPhos-53 TotBili-0.3
[**2145-4-13**] 07:17PM Albumin-3.5 Calcium-9.1 Phos-3.3 Mg-2.1
[**2145-4-13**] 03:00PM ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG

URINE:
[**2145-4-14**] 12:30PM Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.021
[**2145-4-14**] 12:30PM Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG
Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2145-4-14**] 12:30PM RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2
TransE-0-2
[**2145-4-14**] 12:30PM CastHy-0-2

-------
MICRO:
[**2145-4-13**] [**2145-4-15**] Sputum Cx:
PSEUDOMONAS AERUGINOSA
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- DISEASE 8 S
CIPROFLOXACIN--------- Admission Date: [**2145-7-31**] Discharge Date: [**2145-8-2**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Possible GIB DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **]yo M from MACU DISEASE at [**Hospital 100**] Rehab baseline Alert
and Orientedx3 h/o Parkinson's s/p trach multiple DISEASE aspiration
events HTN DISEASE and recent admission s/p possible arrest with cpr
complicated by PTX requiring chest tube now presenting from
rehab with dark output from his g-tube concerning for GI bleed DISEASE .
Per rehab records and patient's wife patient was in his USOH
(sometimes confused but mostly oriented on vent at night with
settings: AC 500X10 FiO2 30% PEEP 5) until about 3 weeks ago
when he had some bleeding DISEASE around his trach site thought [**1-5**]
excessive suctioning. The bleeding DISEASE persisted however so
lovenox (on for DVT DISEASE ppx) was discontinued. The bleeding DISEASE then
stopped but this am he was noted to have 200ML Admission Date: [**2146-7-15**] Discharge Date: [**2146-7-18**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
abdominal pain DISEASE and distention


Major Surgical or Invasive Procedure:
none

History of Present Illness:
[**Age over 90 **]yo from [**Hospital **] rehab with h/o HTN DISEASE osteoperosis and chronic
resp failure [**1-5**] to parkinson's disease DISEASE trached and peged d/t
multiple aspiration events admitted for abdominal distension DISEASE x 7
days and LLQ abdominal pain DISEASE .
.
The patient has a several-year history of bowel difficulty
attribtued to parkinson's disease DISEASE and medication side-effect.
Now he presents with 7 days of abdominal distention DISEASE and RLQ abdominal pain DISEASE relieved intermitently by bowel movements DISEASE . Worse
over last 2 days. No emesis DISEASE or fevers DISEASE . The patient has been
followed at [**Hospital **] rehab where KUB on [**7-13**] showed mildly dilated bowel DISEASE with increased gas. In [**Hospital **] rehab erythromycin was
started to promote peristalsis and a flexiseal was placed. The
patient had a large black guiac neg BM on day of admission but
continued to complain of abdominal discomfort.
.
Of note on [**6-24**] was seen in [**Hospital1 **] ED for leg pain DISEASE and swelling DISEASE as
well as abdominal pain DISEASE . HCT was baseline. LENI was neg for DVT DISEASE .
CT was initially read as unremarkable. Patient was d/c'ed to
rehab final read identified new left anterior iliac bone
fracture DISEASE . At rehab patient was noted to be in considerable pain DISEASE
and grimacing DISEASE with minimal manipulations. He was given ultram
for pain DISEASE control. He was initially on prophylactic lovenox but
this was d/c'ed after Hct of 23.2 on [**7-14**] down from 27.2 on [**7-12**]
for which he recieved 1 unit of PRBC.
.
On admission to ED VS were 99.7 60 129/46 20 99%. Labs showed
UA leukocytes Admission Date: [**2146-8-20**] Discharge Date: [**2146-8-30**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Hypotension DISEASE Hypoxia

Major Surgical or Invasive Procedure:
Trach change [**8-21**] [**8-25**] [**8-26**]. [**Last Name (un) 295**] in place at time of
discharge.
Bronchoscopy [**8-21**]


History of Present Illness:
[**Age over 90 **]yo from [**Hospital **] rehab with h/o HTN DISEASE osteoperosis and chronic
resp failure [**1-5**] to parkinson's disease DISEASE trached and peged d/t
multiple aspiration events brought to the ED from his NH with
concern for AMS. He had an unresponsive episode last night was
reportedly hypoxic (unclear degree). Staff at NH were also
concerned about possible facial droop. The wife rescinded the
DNR order prior to arrival and stated he is to be full code. EMS
suctioned a golf ball sized mucous plug from his trach. He has
had episodes of mucus plugging in the past. Recent
hospitalization for hip fracture DISEASE and ileus DISEASE . Urine culture from
[**7-17**] grew resistant ecoli. He was started on a 7 day course of
ceftriaxone on [**2146-7-18**]. Other micro history: urine w ESBL kleb
resistant ecoli pseudomonas resistant to zosyn DISEASE in sputum and
VRE swab.
.
ED Course: Admission vitals at 0620 53 120/50 15 100. Code
stroke DISEASE called with concern for new facial droop. CT head wo
contrast was negative for acute intracranial hemorrhage DISEASE . Once
family arrived they confirmed that facial droop was old. Pt was
documented DNR but was reversed for transport. Family also
clarified that code status is NO COMPRESSIONS but would want
epinephrine and similar drugs. Started ceftriaxone 1g for
presumed UTI DISEASE . Briefly hypotensive DISEASE to 80's at 7am got 1L IVF.
Vitals prior to transfer: 121/53 55 13 100% on vent (FiO2
40% tidal volume 500 PEEP 5 rr 13). Access: 20g hand 22g
hand 18 R forearm. Foley catheter from rehab not exchanged.
.
On the floor pt c/o L hip pain DISEASE .


Past Medical History:
1. h/o aspiration PNA - Tx with levo unasyn vanco/zosyn in the

past
2. h/o aspiration s/p swallow eval with swallowing difficulty
s/p [**Date Range 282**] placement on [**10-9**] - pt continues to feed for pleasure
at HebReb
3. Parkinson disease DISEASE
4. Osteoporosis DISEASE
5. T11/12 compression fx
6. LLE osteomyelelitis as a child/Chronic osteomyelitis DISEASE
quiescent.
7. granulomatous liver disease DISEASE
8. LUE rotator cuff tear
9. Prostate cancer DISEASE s/p orchiectomy in [**2126**]
10. s/p laminectomy L4-5
11. Cataracts DISEASE s/p surgery
[**46**]. Glaucoma DISEASE
13. Hypertension DISEASE
14. h/o of treatment for pseudomonas and aspiration PNA at heb
reb
15. s/p Trach with night ventilator support.
16. s/p wrist fx
17. chronic constipation DISEASE
18. Chronic abd pain- per Heb Reb notes
19. Recent admission following vasovagal DISEASE event at heb/reb DISEASE s/p
chest compressions complicated by PTX s/p chest tube
20. L ant pubic rami fracture DISEASE L ant iliac fracture DISEASE


Social History:
The patient has a sixty-pack-year history of tobacco. He quit in
[**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is a
retired history professor. [**First Name (Titles) **] [**Last Name (Titles) **] no alcohol intake.
- Tobacco: none currently
- Alcohol: none currently
- Illicits: none


Family History:
Non-contributory

Physical Exam:
Admission Physical Exam:
Vitals: T: 97.5 BP: 104/45 P:75 R:14 O2: 100% (FiO2 40% tidal
volume 500 PEEP 5)
General: Alert elderly male trach on vent no acute distress
HEENT: Sclera anicteric MMM oropharynx clear
Neck: supple trach site intact no LAD
Lungs: diffuse wheezes and rhonchi DISEASE to auscultation
CV: Regular rate and rhythm normal S1 Admission Date: [**2147-9-25**] Discharge Date: [**2147-9-29**]


Service: MEDICINE

Allergies DISEASE :
Valium

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **]M h/o HTN DISEASE osteoperosis and chronic resp failure [**1-5**] to
parkinson's disease DISEASE trached and peged d/t multiple aspiration
events recent pneumonia DISEASE and SIADH who was brought to the ED
from his NH with concern for AMS. Per my discussion with his
wife over the last 10 days he has been less interactive and
today has been moaning. At baseline the patient requires
extensive pulmonary toilet and today was noted to have
worsening secretions. No fevers DISEASE documented in the rehab
facility. Additionally she reports that he has new abdominal
distension.

In the ED initial VS were: 62 129/55 20 100%. He underwent
CT head and CT abdomen. CT head did not show any acute process.
CT abdomen shows a likely infectious DISEASE process in the right lower
lobe concerning for necrotizine pneumonia. He also had a UA
with 129 WBC's few bacteria and large leukesterase. In the ED
he was started on vancomycin cefepime and flagyl. He was noted
to be hypotensive DISEASE but was not responsive to IVF resusitation.
As a result he was placed on norepinepherine. Prior to transfer
to the floor his SBP was in the 120s.

On arrival to the MICU the patient was unresponsive on
ventilator. Additional history or review of systems were
unobtainable.

Past Medical History:
1. h/o aspiration PNA - Tx with levo unasyn vanco/zosyn in the

past
2. h/o aspiration s/p swallow eval with swallowing difficulty
s/p [**Month/Day (2) 282**] placement on [**10-10**] - pt continues to feed for pleasure
at HebReb
3. Parkinson disease DISEASE
4. Osteoporosis DISEASE
5. T11/12 compression fx
6. LLE osteomyelelitis as a child/Chronic osteomyelitis DISEASE
quiescent.
7. granulomatous liver disease DISEASE
8. LUE rotator cuff tear
9. Prostate cancer DISEASE s/p orchiectomy in [**2126**]
10. s/p laminectomy L4-5
11. Cataracts DISEASE s/p surgery
[**46**]. Glaucoma DISEASE
13. Hypertension DISEASE
14. h/o of treatment for pseudomonas and aspiration PNA at heb
reb
15. s/p Trach with night ventilator support.
16. s/p wrist fx
17. chronic constipation DISEASE
18. Chronic abd pain- per Heb Reb notes
19. Recent admission following vasovagal DISEASE event at heb/reb DISEASE s/p
chest compressions complicated by PTX s/p chest tube
20. L ant pubic rami fracture DISEASE L ant iliac fracture DISEASE


Social History:
The patient has a sixty-pack-year history of tobacco. He quit in
[**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is a
retired history professor. [**First Name (Titles) **] [**Last Name (Titles) **] no alcohol intake.
- Tobacco: none currently
- Alcohol: none currently
- Illicits: none


Family History:
Non-contributory

Physical Exam:
ADMISSION PHYSICAL EXAM DISEASE
General: unresponsive trached on ventilator
HEENT: Sclera anicteric MMM left pupil 4mm right pupul 2mm
Neck: supple
CV: RRR normal S1 Admission Date: [**2127-9-20**] Discharge Date: [**2127-9-30**]

Date of Birth: [**2077-7-23**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Left Occipital Epidural Hematoma DISEASE

Major Surgical or Invasive Procedure:
Evacuation of left occipital epidural hematoma DISEASE


History of Present Illness:
50yo WF with PMH significant for cervical disc herniation DISEASE
that presented to outside neurosurgeon 2-2.5 weeks ago for
evaluation. Following that appointment for which no intervention

was pursued patient started to have episodes of falling to the
ground with any attempt at standing up. Patient denied HA
seizure DISEASE activity/symptoms LOC or lightheadedness with each
episode simply stating that Admission Date: [**2182-6-23**] Discharge Date: [**2182-6-28**]

Date of Birth: [**2119-7-11**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Atenolol / Vasotec

Attending:[**First Name3 (LF) 3574**]
Chief Complaint:
Mental status changes

Major Surgical or Invasive Procedure:
none

History of Present Illness:
62 yo F with h/o HTN hypertensive heart disease DISEASE who presents
with two days of fever nausea vomiting DISEASE and mental status
changes. Patient is confused and has poor insight into her
recent symptoms and reasons for presentation to the hospital. Admission Date: [**2130-6-13**] Discharge Date: [**2130-6-16**]

Date of Birth: [**2068-8-5**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Ciprofloxacin / Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC:[**CC Contact Info 3582**]

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI:61yo female from OSH who was found at the bottom of a
staircase approximately 2.5hrs ago. EMS called and pt
transported to [**Hospital3 3583**]. At scene pt noted to be awake
and alert. GCS DISEASE at [**Hospital3 3583**] 6. Intubated at approx. 18:40


Past Medical History:
PMHx: Seizure disorder DISEASE Admission Date: [**2146-7-1**] Discharge Date: [**2146-7-4**]

Date of Birth: [**2088-9-20**] Sex: M

Service: [**Hospital Unit Name 196**]

Allergies DISEASE :
Percocet / Shellfish

Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
Chest Pain DISEASE

Major Surgical or Invasive Procedure:
Cardiac Catheterization

History of Present Illness:
57M h/o HTN hypercholesterolemia DISEASE AAA PVD CAD who presented
to OSH with SSCP [**8-28**] radiating the left arm and back starting
at 4am on the morning PTA. He also had diaphoresis vomiting DISEASE
SOB w/ wheezes. At OSH he received NTG ativan fentanyl and
morphine without sig relief. Was also give lasix lopressor and
started on plavix nitro gtt and heparin gtt. CTA was neg for
PE. ECG showed ST depressions DISEASE in V1-V3 inferior ST elevation.

Past Medical History:
1. arthritis DISEASE
2. intermittent claudication DISEASE
3. HTN DISEASE
4. hypercholesterolemia DISEASE
5. barrett's esophagus
6. renal calculi DISEASE
7. CAD
8. AAA
9.s/p abodominal hernia repair
10.cholecystectomy
[**52**]. shoulder surgery
[**53**]. remote seizure DISEASE

Social History:
smokes 1 pack/day since age 16
occasional ETOH
lives with wive and daughter

Family History:
HTN DISEASE No known early MI/CAD.

Physical Exam:
VS - T98.3 P83 R12 BP111/68 97%RA
Gen - drowsy but arousable
HEENT - anicteric no conjunctival pallor DISEASE no oral findings no
LAD neck supple
CV - RRR nml S1/S2 no M/G/R. No JVD.
Resp- CTAB. Snoring DISEASE loudly. No incr WOB.
GI - Pos BS S/NT/ND. No HSM/Masses.
Neuro - Sleepy but arousable. PERRL. EOMI. Withdraws all ext.
Strength V/V.
Ext - No C/C/E.

Pertinent Results:
[**2146-7-1**] 11:55PM GLUCOSE-97 UREA N-16 CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-30* ANION GAP-11
[**2146-7-1**] 11:55PM CK(CPK)-159
[**2146-7-1**] 11:55PM CK-MB-8 cTropnT-0.23*
[**2146-7-1**] 11:55PM MAGNESIUM-2.0
[**2146-7-1**] 11:55PM WBC-8.0 RBC-4.58* HGB-14.6 HCT-39.9* MCV-87
MCH-31.9 MCHC-36.6* RDW-13.3
[**2146-7-1**] 11:55PM PLT COUNT-161
[**2146-7-1**] 11:55PM PT-13.2 PTT-27.9 INR(PT)-1.1
[**2146-7-1**] 03:41PM TYPE-ART PO2-159* PCO2-49* PH-7.42 TOTAL
CO2-33* BASE XS-6
[**2146-7-1**] 03:05PM CK(CPK)-165
[**2146-7-1**] 03:05PM CK-MB-8 cTropnT-0.21*
[**2146-7-1**] 03:05PM PLT COUNT-171

Brief Hospital Course:
Mr. [**Known lastname 2072**] was admitted to [**Hospital1 18**] from an OSH for ACS DISEASE .

1. CAD/ACS. OSH reported ECG with ST depressions in
V2-V5/Elevation in III and negative CEAdmission Date: [**2123-8-15**] Discharge Date: [**2123-8-18**]

Date of Birth: [**2078-9-26**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Bactrim / Lamivudine

Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
central line
intubation
paracentesis

History of Present Illness:
Hx per family and patient

This is a 44 year old gentleman with HIV on HAART (CD4 376 vl
6000 in [**8-2**])hepatitis C cirrhosis DISEASE who was brought in to ED by
family after he was not returning phone calls for 6 days. His
father and brother found him lying in bed with soilage around
him--the house was in disarray. The patient appeared Admission Date: [**2116-7-3**] Discharge Date: [**2116-7-18**]


Service: MEDICINE

Allergies DISEASE :
Ticlid

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Diarrhea DISEASE and hypotension DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is a 86 y/o male with a h/o CAD CHF DISEASE (EF 30-40%) HTN MDS DISEASE
recent admission in [**7-13**] for diarrhea DISEASE and treated
presumptively for c diff given his past history of c diff
enterocolitis DISEASE who now presents to the ED with
n/v/weakness/dehydration/diarrhea/epigastric abd pain DISEASE x 24
hours. Pt also had one episode of emesis DISEASE (no blood) yesterday.
He is still on his course of flagyl from recent admission but
has missed the last few doses due to outpt pharmacy issues.
.
In the [**Name (NI) **] pt was noted to have an elevated lipase and amylase
of 557 and 900 respectively. He was also noted to have an
elevated lactate of 3.2 and a positive u/a with 6-10 wbc's
trace leuks neg nitrates. He was initially to be admitted to
medicine however pt dropped his SBP from 110 to 90
asymptomatic. Received 500 cc with good response and current SBP
in the 100's. Received a total of 1 L NS. He was given
Vanc/CTX/flagyl in the ED for h/o MRSA positive u/a and recent
h/o c diff enterocolitis DISEASE ([**4-10**]).
.
Currently through aid of daughter translating pt denies any
f/c/s dizziness/lightheadedness chest pain DISEASE SOB palpitations DISEASE
n/v abdominal pain DISEASE urinary symptoms. Admission Date: [**2132-10-6**] Discharge Date: [**2132-10-12**]

Date of Birth: [**2058-10-28**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Known firstname 1283**]
Chief Complaint:
CP / CAD

Major Surgical or Invasive Procedure:
Iliac and aortic stent placement [**2132-10-6**]
Re-do CABG X 4 AVR(tissue) [**2132-10-7**]


History of Present Illness:
This is a 73-year-old male who had a history of
coronary artery disease DISEASE and had underwent a left internal
mammary artery H grafted with a radial artery to the left
anterior descending artery through a left anterior
thoracotomy many years ago. He had progressive shortness of breath DISEASE and was found to have critical aortic stenosis DISEASE with
aortic valve area of 0.8 cm squared and moderate mitral
regurgitation. His ejection fraction was estimated to be
about a 25%. He also underwent a cardiac catheterization
which demonstrated that his H graft to the left anterior
descending artery was patent. He had a totally occluded left
anterior descending artery proximally. He also had
significant stenosis of his left circumflex artery and right
coronary artery.

It was recommended that he undergo a coronary artery bypass
grafting aortic valve replacement and possible mitral valve
repair/replacement. After the risks and benefits were
explained to the patient he agreed to proceed.


Past Medical History:
lisinopril 30' coreg 3.125Admission Date: [**2177-1-26**] Discharge Date: [**2177-2-2**]

Date of Birth: [**2129-2-28**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p MVC

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 47 year old female who was in a motor scooter accident
in [**Country 3594**] 2 days ago. She reportedly had loss of consciousness DISEASE
and was admitted overnight in a hospital in [**Country 3594**]. Yesterday
she presented to [**Hospital6 2561**] complaining of a headache DISEASE
and right elbow pain DISEASE . A CT of the head there demonstrated right
skull fractures DISEASE and a small left intraparenchymal hemorrhage DISEASE .
The patient was transferred here in stable condition. Other than
her headache DISEASE she is complaining of slight dizziness DISEASE but has no
focal neurologic complaints DISEASE .

Past Medical History:
Depression DISEASE

Social History:
The patient is married. She occasionally drinks alcohol.

Family History:
Non-contributory

Physical Exam:
On admission:

Afebrile stable vitals

Gen: pleasant well-developed/well-nourished young female
Neuro: GCS 15 alert oriented x 3 pupils 2--Admission Date: [**2168-12-13**] Discharge Date: [**2168-12-26**]

Date of Birth: [**2141-2-21**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: This is as 27-year-old male with
history of schizophrenia DISEASE and non compliance with medications
who was transferred from [**Hospital **] Hospital as a trauma DISEASE . The
patient reportedly ran in front of a car on route 128. The
patient was walking in the accessory [**Male First Name (un) **] of the highway was
struck by a car that was taking the exit ramp. This occurred
at a slow velocity. The patient was found face down with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 2611**] coma DISEASE scale of 3 and in the prehospital stage was
hemodynamically stable with strong pulses and intact gag
reflex but dilated and fixed pupils. The patient was
subsequently transferred to [**Hospital **] Hospital and intubated.
He was then transferred to [**Hospital1 188**] for definitive care. On arrival the patient was found
to have a superficial open head laceration DISEASE a left open tibia
and fibula fracture DISEASE and a laceration to the right upper
extremity. The patient had received 1 gm of Ancef prior to
arrival in the Emergency Room.

PAST MEDICAL HISTORY: Schizophrenia. He has not been
compliant with medications and has been increasingly paranoid DISEASE
per the patient's father. There is question of a history of
rhythm disorder DISEASE .

MEDICATIONS: Neurontin Risperdal.

ALLERGIES: No known drug allergies DISEASE .

PAST SURGICAL HISTORY: Adenoidectomy tonsillectomy and left
upper extremity fracture DISEASE .

SOCIAL HISTORY: The patient lives at the [**Company 3596**] in [**Hospital1 **].
Father lives in [**Hospital1 3597**]. The patient smokes and drinks alcohol
but denies recreational drug use.

PHYSICAL EXAMINATION: The patient initially had a heart rate
of 100 blood pressure 160/94 respiratory rate was
determined by respiratory therapist as he was intubated. He
was satting 100%. The patient had a large equalizing
posterior scalp avulsion and forehead laceration DISEASE . These were
closed immediately with staples. His left tympanic membrane
was clear his right tympanic membrane had a question of
hemotympanum. His C spine was collared. There were no
step-offs. Chest is clear to auscultation bilaterally.
Abdomen was soft nontender non distended. Pelvis is
stable. There was decreased rectal tone and no gross blood.
He had palpable dorsalis pedis pulses bilaterally and an open
fracture DISEASE at the left shin.

LABORATORY DATA: White blood cell count 25.7 hematocrit
43.3 platelet count 310000 fibrinogen 142. Urine
specific gravity 1.032 PH 5.0 [**7-10**] red blood cells rare
bacteria. Sodium 137 potassium 4.5 chloride 101 CO2 28
BUN 10 creatinine 1.0 glucose 137 amylase 63. Serum
toxicology screen was negative. Urine toxicology was also
negative. Initial blood gas had PH 7.46 PCO2 40 PO2 287
bicarb 29. A trauma DISEASE series including AP view of the chest
lateral C spine and AP view of the pelvis were read as
negative. CT of the C spine showed a linear non displaced
fracture DISEASE of the pars intraarticularis at C7. A CT of the
head showed a very small amount of subarachnoid blood seen on
the right tentorium. CT of the chest abdomen and pelvis
showed only a small area of consolidation in the left upper
lobe and bibasilar DISEASE dependent atelectasis DISEASE . There was no
evidence of other injuries DISEASE . The left tib fib film showed a
mid shaft comminuted left tibial and fibular fracture DISEASE . A
left elbow x-ray was normal. T spine and LS spine x-rays
were also normal.

HOSPITAL COURSE: The patient was brought to the operating
room by orthopedic surgery for repair of the left tibia and
fibular fractures DISEASE and open reduction and internal fixation
was performed with placement of an intramedullary rod. The
patient tolerated the procedure well and was subsequently
admitted to the Surgical Intensive Care Unit for close
monitoring. In the unit neurosurgery was consulted who
commented on the questionable area of subarachnoid
hemorrhage DISEASE . Their recommendation was to load with Dilantin
which was promptly done. On hospital day #2 the patient was
completely stable. Spine surgery was consulted for the C7 to
T1 facet fracture DISEASE who recommended that the patient continue
the C collar for approximately 6 weeks. The patient was
placed on antibiotic prophylaxis with Ancef throughout his
Intensive Care stay. The patient was transferred to the
floor on [**2168-12-16**]. He was seen by psychiatry and followed up
throughout the next several days. He remained markedly
confused with disorganized speech. This was initially felt
to be consistent with the schizophrenia DISEASE although after
several days of evaluation it was determined that this is
likely a component of traumatic DISEASE brain injury as well.
Neurology was consulted and recommended MRI of the patient's
head. This study showed multiple areas of low signal
insusceptibility images at the [**Doctor Last Name 352**] white matter junction
indicative of diffuse axonal injury DISEASE and bilateral frontal
subdural effusion DISEASE . There was also a large hematoma DISEASE seen
which was followed while the patient was on the hospital
floor. It was determined that the patient would benefit from
a neuro rehab facility. Case management screened the patient
and placement is currently pending. The patient was kept on
a 1:1 sitter throughout his entire hospital course. Physical
therapy followed him for exercises. His range of motion
instructions at discharge are weight bearing as tolerated on
the left lower extremity. Dilantin was slowly weaned to off
on [**2168-12-25**].

DISCHARGE MEDICATIONS: Heparin 5000 units subcu [**Hospital1 **] while
the patient is confined to bed. Risperdal 3 mg po bid
Percocet [**2-2**] q 4 hours prn severe pain DISEASE Tylenol 1 gm po q 4
hours prn pain DISEASE .

DISCHARGE DIAGNOSIS:
1. Status post struck by car.
2. Head trauma DISEASE with diffuse axonal injury DISEASE .
3. Schizophrenia.
4. Left tibia and fibula fracture DISEASE status post open reduction
and internal fixation.
5. C7 facet fracture DISEASE .




[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**] MD [**MD Number(1) 3599**]

Dictated By:[**Last Name (NamePattern1) 3600**]
MEDQUIST36

D: [**2168-12-26**] 11:50
T: [**2168-12-26**] 13:14
JOB#: [**Job Number 3601**]
Admission Date: Discharge Date: [**2169-1-9**]

Date of Birth: Sex: M

Service:

ADDENDUM: The patient has been on a one to one sitter for
quite some time. He however was placed in a Veil bed last
week and the patient has been without a one to one sitter and
doing well for approximately four days now. Since the
screening process has been reinstituted and the patient is
just awaiting a rehab placement.





DR.[**Last Name (STitle) 3598**][**First Name3 (LF) **] 02-352


Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36

D: [**2169-1-9**] 09:55
T: [**2169-1-9**] 10:18
JOB#: [**Job Number 3602**]
Admission Date: [**2167-3-12**] Discharge Date: [**2167-3-15**]

Date of Birth: [**2107-10-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
Cardiac catheterization
Swan-Ganz catheter placement
Endotracheal intubation

History of Present Illness:
59 year old gentleman with a past medical history of CAD s/p
CABG in [**2151**] with LIMA to LAD and RIMA to RCA hyperlipidemia DISEASE
htn and smoking. The patient was having symptoms of shortness DISEASE
of breath and chest pain DISEASE unclear for how long and decided to go
to his PCP who he had not seen in over two years. On route to
the office his symptoms worsened and he called his doctor who
advised him to pull over and call 911. Taken by Ambulance to
[**Hospital1 **] ER at 1130. There he received 325 aspirin 4 morphine
and nitroglycerin drip. Arixtra (Fondiparinux) was also given.
EKG revealed ST depressions in leads I aVL V3-V6. ST elevation
in AVR. CK 99 MB and troponin unknown. The patient had worsened
dyspnea DISEASE and hypoxia DISEASE had pulmonary edema DISEASE on CXR and was
electively intubated (etomidate succinylcholine). Integrilin
started and sent for catheterization. Left heart cath via right
femoral artery reportedly with 95% lm occlusion native RCA and
LAD are both occluded. LIMA and RIMA appeared patent.
.
Pt received 40 IV lasix and transferred to [**Hospital1 18**] for further
intervention. Became hypotensive DISEASE to SBP 70-80 and was placed on
neo gtt on route. On arrival to cath lab pt still pressor
dependent. Cath revealed critical Admission Date: [**2133-1-6**] Discharge Date: [**2133-1-8**]

Date of Birth: [**2090-3-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
PCP: [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 3604**]
.
CHIEF COMPLAINT: visual changes
REASON FOR MICU ADMISSION: PCN desensitization.


Major Surgical or Invasive Procedure:
PCN desensitization

History of Present Illness:
Pt is a 42 y.o male with h.o HIV (last CD4 479 VL 13700) not
on HAART who was started on doxycycline (PCN allergy) 5 days ago
for secondary syphilis (titer 1:64). He reported to his PCP that
he had been having visual problems DISEASE for the past month. He was
sent urgently to ophthal where b/l anterior uveitis DISEASE and b/l disc
edema DISEASE was seen. He was sent to the ED for imaging LP with
thoughts of PCN desensitization. Pt was referred for infectious DISEASE
w/u.
.
Pt states that since [**Month (only) **] he developed chills skin rash DISEASE
(purple/pink spots on torso/arms/face/neck/penis joint pains DISEASE
swollen cervical lymph nodes abdominal bloating ( constipation DISEASE )
as well as visual changes (white lights in periphery white
circles and lines). Pt denies fever DISEASE eye pain photophobia DISEASE neck
stiffness CP/SOB/palp abd
pain/n/v/d/c/melena/brbpr/dysuria/hematuria/parestheisas or
weight loss DISEASE .
Admission Date: [**2130-6-1**] Discharge Date: [**2130-6-7**]

Date of Birth: [**2061-8-26**] Sex: M

Service: SURGERY

Allergies DISEASE :
Codeine / Meperidine / Iodine Containing Agents Classifier

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Autoimmune hepatitis DISEASE
HCC DISEASE

Major Surgical or Invasive Procedure:
Left hepatic lobectomy caudate lobe resection cholecystectomy
intraoperative ultrasound.


History of Present Illness:
The patient is a 68-year-old male with a history of auto-immune DISEASE
hepatitis DISEASE and cirrhosis DISEASE who developed right upper quadrant
abdominal pain DISEASE . An ultrasound demonstrated a large mass in the
right lobe of the liver that on biopsy was consistent with
hepatocellular carcinoma DISEASE . His AFP was 336. A CT scan of the
chest and abdomen demonstrated no evidence of pulmonary
metastases. The patient had a large mass lesion measuring 12.7 x
9.2 x 11.2 cm arising primarily in the medial segment of the
left lobe. The middle hepatic vein was not visualized but the
right hepatic vein and the left lateral segment hepatic veins
were identified. The mass lesion superiorly appears to abut not
invade the right lobe of the liver. The patient does not have
evidence of portal hypertension DISEASE . The patient after informed
consent is now brought to the operating room for left hepatic
lobectomy possible left trisegmentectomy caudate lobe
resection and cholecystectomy.


Past Medical History:
hyperchol HTN DISEASE CAD s/p CABG (echo --Admission Date: [**2157-12-15**] Discharge Date: [**2157-12-23**]

Date of Birth: [**2099-4-13**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Ciprofloxacin / Levaquin / Opioid Analgesics

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**2157-12-15**] Aortic Valve Replacement (21mm CE tissue valve)

History of Present Illness:
58 y/o female with known AS. Followeed by serial echo's and
cardiac cath which have shown progression of aortic stenosis DISEASE .
Admits to increased chest discomfort DOE and fatigue DISEASE over the
last several years.

Past Medical History:
Aortic Stenosis Hypertension Hypercholesterolemia DISEASE Peripheral
[**Month/Day/Year **] Disease Carotid Disease DISEASE End-Stage Renal Disease DISEASE
(prev. on HD DISEASE ) Diabetes Mellitus DISEASE Admission Date: [**2159-4-6**] Discharge Date: [**2159-4-10**]

Date of Birth: [**2120-1-29**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Blurry vision

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 39 year old male with a history of hypertension DISEASE (on
beta blockade lasix hydralazine imdur metolazone)
complicated by chronic kidney disease DISEASE (stage IV) EF of 25-30%
obesity DISEASE and
tobacco abuse DISEASE . He presented today to the emergency room after
[**Hospital 2081**] clinic noted severe bilateral papilledemaAdmission Date: [**2158-6-13**] Discharge Date: [**2158-6-21**]

Date of Birth: [**2099-4-13**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Ciprofloxacin / Levaquin / Opioid Analgesics

Attending:[**First Name3 (LF) 826**]
Chief Complaint:
Recurrent high fevers HTN DISEASE increased O2 req

Major Surgical or Invasive Procedure:
Central venous catheter insertion


History of Present Illness:
59 yo M w/ PMH ESRD DISEASE s/p renal tx in [**2155**] on immunosuppressants
HTN DM DISEASE who presented to OSH with fevers/fatigue and tx to [**Hospital1 18**]
for concern of sepsis DISEASE . He experienced fatigue DISEASE after working
outside in hot weather and later that day was noted to have a
fever DISEASE to 104. He went to [**Hospital **] Hosp where he was febrile DISEASE to
104. He was given levofloxacin and IVFs and transferred to [**Hospital1 18**]
where he was admitted to the ICU for sepsis DISEASE .
.
He denies current f/c/sweats. He denies cp/sob/cough. He denies
n/v/abd pain DISEASE . He denies dysuria DISEASE . He denies URI sx/sore
throat/myalgias. He denies LAD/swelling/rash.

.


Past Medical History:
1. Congestive heart failure DISEASE with EF 65% on [**2158-6-13**]
2. Type 2 diabetes with triopathy DISEASE controlled.
3. Hypertension DISEASE .
4. Hypercholesterolemia DISEASE .
5. History of seizure disorder DISEASE .
6. History of hepatitis C DISEASE - no therapy - [**11-21**] bx -Minimal
portal and lobular mononuclear cell inflammation DISEASE consistent
with involvement by chronic viral hepatitis DISEASE C ( Grade 1
activity).
7. End-stage renal disease DISEASE status post cadaveric renal
transplant creatinine 1.2-1.5
in [**2155-2-16**].
8. Peripheral [**Year (4 digits) 1106**] disease.
9. Post-Op AFIB s/p DCCV in [**2-22**]
10. Rt rectus femoris intramuscular hematoma DISEASE - [**2-22**] (INR 4.2)
11. Admission Date: [**2159-5-26**] Discharge Date: [**2159-6-12**]

Date of Birth: [**2099-4-13**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Ciprofloxacin / Opioid Analgesics / Levaquin

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fever DISEASE

Major Surgical or Invasive Procedure:
Intubation/Extubation
RIJ central line now removed
Lumbar puncture


History of Present Illness:
60 y.o. M with hx of ESRD DISEASE s/p cadaveric renal tx in [**2155**] on
immunosuppressants Hep C HTN DISEASE [**Year (4 digits) 2320**] PVD DISEASE presents from home
with fever to 105.8. Patient says he was in his usual state of
health as recently as Weds when he saw his cardiologist in
preparation for hernia DISEASE repair surgery early next week. Some of
his usual medications including his prophylactic bactrim were
held and he stayed home from work trying to avoid sick contacts
pre-operatively. On Thursday afternoon he started to feel some
malaise and his temperature started to rise. He took some
tylenol and his fever DISEASE appeared initially to abate but returned
[**Year (4 digits) 2974**] with nausea DISEASE and vomiting DISEASE constant shivering DISEASE shoulder
aches headaches DISEASE and three episodes of loose stools. Denies
any urinary symptoms (no changes in color consistency dysuria DISEASE
frequency urgency) abd pain DISEASE neck stiffness cough or cold
symptoms. No sick contacts. [**Name (NI) **] recent travel. He was last
admitted to [**Hospital1 18**] from [**4-23**] to [**5-2**] for new diagnosis of atrial flutter acute on chronic renal failure DISEASE and HAP DISEASE .
.
In the ED patient had labs which showed and elevated white
count with a 10% bandemia DISEASE . He had a CXR which was negative for
any acute process. A R IJ line was placed and he was started on
Vancomycin and Gentamycin for presumptive endocarditis DISEASE . UA
urine culture and blood cultures were sent. No recent invasive
dental work. No recent IVDU.


Past Medical History:
Congestive heart failure DISEASE with EF 65% on [**2158-6-13**]
Type 2 diabetes with triopathy DISEASE controlled.
Hypertension DISEASE .
Hypercholesterolemia DISEASE .
History of seizure disorder DISEASE .
History of hepatitis C DISEASE - no therapy - [**11-22**] bx -Minimal portal
and lobular mononuclear cell inflammation DISEASE consistent with
involvement by chronic viral hepatitis DISEASE C ( Grade 1 activity).
End-stage renal disease DISEASE status post cadaveric renal
transplant creatinine 1.5 in [**2159-4-17**]
Peripheral [**Year (4 digits) 1106**] disease.
Post-Op AFIB s/p DCCV in [**2-22**]
Rt rectus femoris intramuscular hematoma DISEASE - [**2-22**] (INR 4.2)
Admission Date: [**2167-7-31**] Discharge Date: [**2167-8-7**]

Date of Birth: [**2105-6-24**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 62 -year-old
male with known history of coronary artery disease DISEASE status
post myocardial infarction DISEASE with angioplasty in [**2155**]. He has
a history of increased cholesterol family history of heart
disease and states he has had angina DISEASE symptoms for many
years. He said within the last year his symptoms have
increased with concomitant shortness of breath DISEASE . The patient
stated that he was golfing roughly four days prior to
admission and had episodes of left sided chest pains DISEASE which
radiated to the shoulder and arm.

The patient on [**2167-7-29**] presented to an Emergency Room for
rule out myocardial infarction DISEASE and the myocardial infarction DISEASE
was ruled out with enzymes and electrocardiogram. On
[**2167-7-30**] the patient started exercising had increased chest
pains DISEASE for roughly seven minutes which resolved. The patient
was then worked up for a myocardial infarction DISEASE once again and
was transferred to a Catheterization Lab for possible
angioplasty.

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post myocardial
infarction DISEASE in [**2155**].
2. Status post angioplasty of the left circumflex in [**2155**].
3. Gastroesophageal reflux disease DISEASE .
4. Hypertension.
5. Hypercholesterolemia.
6. Benign prostatic hypertrophy DISEASE .
7. Dupuytren contractures.

ADMITTING MEDICATIONS: Include Lipitor 40 mg Cardizem 120
mg q day aspirin 325 mg q day Flomax 0.4 mg q day Ambien
5.0 mg HS and Ativan 0.5 mg tid prn.

ALLERGIES: Include contrast dye.

PHYSICAL EXAMINATION: On initial examination vital signs:
blood pressure 150/90 heart rate 50. Neck: negative jugular
venous distention DISEASE . Chest is clear to auscultation. Heart:
regular rate and rhythm. Abdomen: soft nontender positive
bowel sounds. Extremities: Admission Date: [**2115-7-2**] Discharge Date: [**2115-7-15**]

Date of Birth: [**2052-5-19**] Sex: F

Service: ORTHOPAEDICS

Allergies DISEASE :
Percocet

Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
back pain buttock pain DISEASE and exacerbated leg pain DISEASE

Major Surgical or Invasive Procedure:
1. Bilateral L3 laminotomies medial facetectomies and
foraminotomies of the L4 nerve root.
2. Bilateral laminectomy of L5 with medial facetectomy of L4-L5
and foraminotomies bilaterally at the L5 nerve roots.
3. Complex repair and allograft placement of a dural tear.
4. Placement of lumbar drain L1-2.


History of Present Illness:
Mrs. [**Known lastname 1391**] was having anterior quads symptoms and leg
symptoms that were on top of her acute chronic back pain. She
is currently on MS Contin and Neurontin. She is [**8-28**] at rest
[**9-27**] with activity. However she is almost 90% back pain DISEASE and
this is what stops her and not leg pain DISEASE . She has had
significant benefit from mild ablation in her back previously.
Her thigh pain DISEASE has certainly settled down on the Neurontin.

Past Medical History:
Asthma
COPD DISEASE
hypothryroidism DISEASE
Depression DISEASE
hyperlipidemia DISEASE

Social History:
Currently married smokes cigarettes

Family History:
Colon CA

Physical Exam:
On Discharge:
AAdmission Date: [**2161-2-14**] Discharge Date: [**2161-3-10**]

Date of Birth: [**2098-9-3**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: This 61 year-old male with a ten
year history of progressive Parkinson's disease DISEASE tripped over
his own feet and fell down approximately seven steps. He
states for a few seconds he was stunned and felt tingling in
all four extremities. He also noted pain DISEASE in his legs left
greater then right and in his right chest. He was taken to
[**Hospital **] Hospital where he was reportedly neurologically
intact. He was in a cervical collar. A CT scan of the
cervical spine was obtained. This showed a fracture DISEASE of the
anterior arch of C1. There was a moderately displaced
comminuted odontoid fracture DISEASE extending through the base
which moderately narrowed the spinal canal. The dens and C1
were displaced approximately 13 mm. The patient was able to
void spontaneously times two before a Foley catheter was
placed. The patient has been followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
Neurology for his movement disorder DISEASE .

PAST MEDICAL HISTORY: The patient has a history of bipolar DISEASE
disorder and Parkinson's syndrome DISEASE .

ALLERGIES: He is allergic DISEASE to Haldol.

MEDICATIONS:
1. Sinemet.
2. Folate.
3. Valproic acid.
4. Seroquel.
5. Amantadine.

LABORATORIES ON ADMISSION: White blood cell count of 9.3
hematocrit 41.4 platelet count 157 amylase 42 sodium 143
potassium 5.0 chloride 106 CO2 28 BUN 22 creatinine 1.1
glucose 122 lactacid 1.6.

PHYSICAL EXAMINATION: The patient is alert and oriented
times three. He is complaining of a headache DISEASE posterior neck
pain DISEASE and right chest pain DISEASE . He has a marked resting tremor DISEASE
primarily effecting his left upper extremity and left lower
extremity. There is cogwheel rigidity DISEASE of both upper
extremities. His cranial nerves are intact. He describes
altered sensation and pain DISEASE to light touch and pin prick over
his left occiput and right chest at approximately the T2 to
T5 levels. There is no clear sensory level to pin prick
light touch position direction or vibration. The patient's
cervical collar fits DISEASE well. His toes are upgoing. His
reflexes are 2Admission Date: [**2171-6-4**] Discharge Date: [**2171-6-21**]

Date of Birth: [**2092-5-17**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Fosamax / Actonel / Iodine / Solu-Cortef / Advair Diskus

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing DOE

Major Surgical or Invasive Procedure:
CABGx1(SVG-Service: Date: [**2129-10-12**]

Date of Birth: [**2077-7-1**] Sex: F

Surgeon: [**Name6 (MD) 3661**] [**Name8 (MD) 3662**] M.D.

PREOPERATIVE DIAGNOSIS:

POSTOPERATIVE DIAGNOSIS:

CHIEF COMPLAINT: Tetany muscle spasms DISEASE .

HISTORY OF THE PRESENT ILLNESS: The patient is a 52-year-old
female who awoke on the morning of admission with body
tingling. She felt numb DISEASE and felt as though she had trouble
moving her arms and legs. At 8 o'clock on the morning of
admission the patient called the EMS. She was otherwise in
her usual state of health. She has noticed over the past
several day constipation DISEASE which was treated with PO Dulcolax
with several watery stools the day before admission.

PAST MEDICAL HISTORY:
1. History of seizure disorder DISEASE .
2. Hypotension.
3. Fibromyalgia.
4. Hypoxic brain injury secondary to overdose DISEASE .
5. Depression with several suicide attempts.

MEDICATIONS ON ADMISSION:
1. Prozac 40 mg PO b.i.d.
2. Klonopin 2 mg PO q.i.d.
3. Flexeril 10 mg PO t.i.d.
4. Ibuprofen 600 mg PO q.i.d.
5. [**Doctor First Name **] 60 mg PO b.i.d.
6. Risperdal 2 mg PO b.i.d.
7. Colace 100 mg PO b.i.d.
8. Albuterol/Atrovent MDIs p.r.n.

ALLERGIES: The patient is allergic to PENICILLIN AND
CODEINE.

REVIEW OF SYSTEMS: The patient has no headache DISEASE no visual
changes no nausea no vomiting no fever DISEASE no chills DISEASE no
seisure no changes in diet no abdominal pain DISEASE no shortness
of breath no chest pain DISEASE no changes in medications recently.

SOCIAL HISTORY: The patient has positive tobacco use. No
alcohol use.

PAST MEDICAL HISTORY: The patient has history of multiple
recreational drug use.

PHYSICAL EXAMINATION: Examination on admission revealed the
following: Temperature 96.9 blood pressure 108/48 heart
rate 80s respiratory rate 20. Oxygen saturation 98% on two
liters. GENERAL: The patient was alert oriented times
three. Oropharynx was dry. Neck was supple with
jugulovenous distention. CARDIOVASCULAR: Regular rate and
rhythm normal S1 and S2. LUNGS: Bibasilar crackles.
ABDOMEN: Soft nontender nondistended normoactive bowel
sounds. No hepatosplenomegaly DISEASE . EXTREMITIES: Warm with good
pulses no edema. NEUROLOGICAL: Extraocular muscles are
intact. Pupils equal round reactive to light and
accommodation. MOUTH: Clenched closed tongue midline.
SENSORY: Sensory examination was normal. Strength 5/5 in
all muscle groups. Reflexes: 0 through 1 throughout.

LABORATORY DATA: Labs on admission revealed the following:
White blood count 8.0 hematocrit 32.8 platelet count
287000 INR 1.2 PTT 23.5 sodium 137 potassium 2.4
chloride 92 bicarbonate 29 BUN 13 creatinine 0.9 glucose
74 magnesium 1.0 free calcium 0.78 CK 128 troponin less
than 0.3. ABG: The pH was 7.51 CO2 40 pO2 45 toxicology
screen negative. Chest x-ray revealed mild congestive heart
failure. Echocardiogram: Mild MR normal left ventricular
ejection fraction greater than 55%. EKG: Normal sinus
rhythm PR of 0.174. QTC: 476 milliseconds slightly
prolonged compared to previous.

HOSPITAL COURSE: In the ED the patient received one ampule
of calcium 2 grams of magnesium 6 liters of fluid. The
patient was treated with Levofloxacin Flagyl and
Hydrocortisone.

The patient was admitted to the Medical Intensive Care Unit
for management of electrolytes. The patient was given
several ampules of calcium gluconate with improvement of the
free calcium as well as the total calcium. On [**10-11**] in the morning the patient admitted to using Dulcolax
on a daily basis and also frequent use of Fleet Phospho-Soda
enemas and wanted to make sure that the staff knew that this
could be the possible etiology of her current symptoms.

The patient was continued to be hydrated with IV fluids.
Electrolytes were repleted. Calcium continued to improve.
The patient was transferred to the floor for management.
Calcium was then repleted with one gram PO calcium carbonate
with improvement of free calcium to a normal range. All
other electrolytes were repleted as well.

The Department of Psychiatry was consulted for evaluation of
the patient laxative abuse. It was felt that the use was
secondary to constipation and not likely due to body
dysmorphic disorder or attempts to lose weight. However
recommend follow up as an outpatient which the patient will
do through her outpatient therapist as well as her primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. The patient agrees to use
nonstimulant bowel regimen which included Milk of Magnesia
Colace and Senna. The patient will follow up with the
primary care physician for better bowel regimen management
and possible gastrointestinal follow up. At the time of
discharge the patient's symptoms of tetany DISEASE and muscle spasms DISEASE
had completely resolved and the electrolytes were normalized.

DISCHARGE DIAGNOSES:
1. Hypocalcemia.
2. Laxative abuse.

CONDITION ON DISCHARGE: Good.

MEDICATIONS ON DISCHARGE:
1. Prozac 40 mg PO b.i.d.
2. Klonopin 2 mg PO q.i.d.
3. Flexeril 10 mg PO t.i.d.
4. Ibuprofen 600 mg PO q.i.d.
5. [**Doctor First Name **] 60 mg PO b.i.d.
6. Risperdal 2 mg PO b.i.d.
7. Colace 100 mg PO b.i.d.
8. Albuterol/Atrovent MDI p.r.n.
9. Senna one tablet PO q.h.s.
10. Milk of Magnesia PO p.r.n. constipation DISEASE .
11. Calcium carbonate one gram PO b.i.d.

FOLLOW-UP CARE: The patient is to follow up with her primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who was Emailed. The patient will
see Dr. [**Last Name (STitle) **] later this week or possibly the week after.




[**Name6 (MD) 251**] [**Name8 (MD) **] M.D.

Dictated By:[**Doctor Last Name 3663**]

MEDQUIST36

D: [**2129-10-12**] 16:07
T: [**2129-10-13**] 15:05
JOB#: [**Job Number 3664**]
Admission Date: [**2131-12-18**] Discharge Date: [**2132-1-1**]

Date of Birth: [**2077-7-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Meperidine & Related / Codeine / Propoxyphene

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
admit to [**Hospital Unit Name 153**] for RML pneumonia hypotension

Major Surgical or Invasive Procedure:
Intubation [**12-21**]


History of Present Illness:
54yo woman presented to the ED with 2 days of fevers cough DISEASE and
muscle aches DISEASE . Also had right sided sharp stabbing [**10-28**]
pleuritic chest pain DISEASE and shortness of breath DISEASE exacerbated by
cough DISEASE or inspiration. No anginal symptoms DISEASE . In ED received
ceftriaxone azithromycin as well as aspirin. Initial SBP in
the 80's and received 3L NS and started on levophed gttAdmission Date: [**2134-2-28**] Discharge Date: [**2134-3-19**]

Date of Birth: [**2077-7-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Meperidine & Related / Codeine / Propoxyphene

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hypotension acidemia hyponatremia tachypnea DISEASE

Major Surgical or Invasive Procedure:
intubation central line placement.

History of Present Illness:
56-year-old female with a history of chronic abdominal pain DISEASE
laxative abuse DISEASE and chronic diarrhea DISEASE who complained of shorness
of breath. Had been admitted for worsening abdominal
pain/distension chills DISEASE and diarrhea DISEASE . CT demonstrate illeus vs.
low grade SBO. Had been stable on floor.
.
Upon evaluation of patient by floor team she had a RR in the
30's but oxygenating well on 4L NC. Patient complained of
worsening abdominal pain shortness of breath DISEASE . BP 82/42 but
decreased to the 70's (baseline BP's in the 80's to 90's). P
110 afebrile. ABG 7.25/27/105/12 on 4L NC (baseline pCO2
50's-60's).
.
Patient with only 22g PIV x 1. Saline started and brought to
unit. Line placed with difficulty. Sterilly prepped for R SC
or R IJ. Unable to locate R subclav after mult sticks (4) and
accessed R SC artery. Then converted to R IJ and accessed with
US. Line placement sterile but may be compromised. Patient
complaining of abdominal pain DISEASE . NGT placed to suction with
feculent material.
.
ABX course in ICU:
[**3-1**]: vanc flagyl cipro for broad coverage
[**3-2**]: UTI DISEASE w/ E.coli DISEASE cipro d/c'd started on ceftriaxone (10 day
course).
[**3-4**]: vanco stopped
[**3-6**]: Started azithromycin for atypical coverage
[**3-7**]: current abx include azithro vanco and zosyn. the flagyl
and ctx were stopped.
.
Vancomycin: [**Date range (1) 3698**]
Flagyl: [**3-1**] - [**3-7**]
Ceftriaxone [**3-2**] - [**3-7**]
Azithromycin: [**3-6**] - [**3-9**]
Zosyn: [**3-7**] - [**3-10**]



Past Medical History:
1. History of laxative abuse DISEASE
2. Anorexia nervosa DISEASE
3. Bipolar disorder DISEASE
4. Borderline personality disorder DISEASE
5. Seizure DISEASE disorder- Pt's last seizure DISEASE was in [**2126**] - reportedly
in the setting of alcohol withdrawal.
6. PTSD DISEASE
7. H/O multiple suicide attempts - cut wrists and multiple drug
ODs
8. CHF DISEASE is listed as a diagnosis but her ECHO is normal and she

has not clinically been in heart failure DISEASE recently per history.
9. Breast cancer DISEASE s/p resection- Pt was not treated with chemo or

radiation therapy.
10. H/O Bell's palsy DISEASE
11. [**Name (NI) 3672**] Pt is on 2L oxygen at home. (reduced DLCO but
restrictive physiology on PFTs)
12. Fibromyalgia
13. Arthritis DISEASE
14. Admission Date: [**2136-2-28**] Discharge Date: [**2136-3-7**]

Date of Birth: [**2077-7-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Meperidine & Related / Codeine / Propoxyphene

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Dyspnea DISEASE and pleuritic chest pain DISEASE

Major Surgical or Invasive Procedure:
Transfusion of 1unit of pRBCs


History of Present Illness:
History of Present Illness: Ms. [**Known lastname **] is 58 year old female with
history of COPD DISEASE Systolic CHF DISEASE (EF 45-50%) Bipolar disease DISEASE
Borderline Personality Disorder DISEASE severe pain depression DISEASE RA
and oxygen use (4L without a clear-cut rationale). She was
admitted today for chest pain DISEASE and dyspnea DISEASE .
.
Ms. [**Known lastname **] reports that she had the flu last week and began
experiencing diffuse chest pain DISEASE (10Admission Date: [**2101-10-25**] Discharge Date: [**2101-10-28**]

Date of Birth: [**2064-10-2**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Cephalosporins / Floxin / Penicillins

Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Xanax Tylenol & Klonopin Overdose DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
37 yo F with history of depression DISEASE and suicidal attempt in the
past presented with obtundation DISEASE . Of note her prior attempt was
about 15 years ago during which she OD on theophylline
requiring intubation. She has been feeling more depressed DISEASE over
the last few months and has been seeing a therapist on the ECT
waiting list with recent evaluation by Dr. [**Last Name (STitle) 2109**] [**First Name3 (LF) **] her
partner. [**Name (NI) **] reports taking 120 mg of Xanax and 80 mg
Klonopin in the afternoon of [**2101-10-25**] as well as at least [**4-7**]
g of Tylenol daily over the last 2 weeks. She also admitted to
taking 20 mg of Ambien. She says that she was taking the
tylenol intentionally to worsen her liver function. She says
that she decided to do this because she wanted to commit
suicide. She also reports having had 1 glass of wine on the day
of these medication ingestions. She then called one of her
friends afterwards and her therapist ([**First Name8 (NamePattern2) 2110**] [**Last Name (NamePattern1) **]) was
subsequently involved and called the EMS for patient.

In the ED her initial VS were HR 99 BP 102/56 RR 20 and 98%
on RA DISEASE . She arrived with her friend very lethargic. Per
report was only responsive to sternal rub and GCS DISEASE of 8
throughout. Tox screen showed positive benzos and acetaminophen
only. ECG showed sinus tachycardia DISEASE . UA was negative. CT head
did not show ICH DISEASE . Her initial Tylenol level was 40. Toxicology
was consulted and recommended NAC for 21 hours until level is
undetectable and LFT stabilizes. She started NAC in the ED and
her repeat level was 29. VS prior to transfer were T95 HR 66
BP 121/73 RR 22 O2Sat 98% RA DISEASE .

She was transferred to the ICU for her poor mental status.
While on the floor appears comfortable denies any SOB chest
pain/discomfort abdominal pain/discomfort urinary symptoms or
URI symptoms. She does have some throat tightness DISEASE and
discomfort when swallowing. Her partner reports that patient's
mental status seems to have improved since her initial arrival
to the ED.


Past Medical History:
- Asthma requiring 1x intubation in late teen (unclear if this
was related to the theophylline)
- GERD with severe esophagitis DISEASE ([**2098**])
- Insomnia
- Bipolar Type 2 currently severe depression DISEASE requiring
hospitalization at [**Doctor First Name **] in the past
- Depression DISEASE
- Suicidal attempts (last [**1-/2099**] following impulsive suicide
attempt in which she crashed her cars 2 other ones with OD in
her late teens)


Social History:
Occupation: a nurse mid-wife at [**Name (NI) 2025**] x 10 years
Drugs: Marijuana last used about 1 week ago
Tobacco: None
Alcohol: occasionally
Married to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 976**] [**Telephone/Fax (1) 2111**] live in [**Location (un) 538**].


Family History:
- mother- depression DISEASE
- maternal grandmother- EtOH abuse benzodiazepine abuse
- maternal uncle- bipolar affective DISEASE d/o


Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 36.9 BP 116/51 HR 65 RR25 O2Sat 99% RA DISEASE
General: lethargic answers questions appropriately but in
whispers follows commands NAD
HEENT: PERRL EOMi anicteric Mucous membrane moist
NECK: no supraclavicular or cervical LAD no JVD no carotid
bruits DISEASE no stridor DISEASE
Resp: CTAB with good air movement throughout no wheeze
crackles or rhonchi
CV: RR S1 and S2 wnl no m/r/g
ABD: soft ND mildly tender in the umbilical area no
hepatosplenomegaly DISEASE no guarding.
EXT: no c/c/e
SKIN: no rashes/no jaundice DISEASE
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits DISEASE to light touch appreciated.

Pertinent Results:
[**2101-10-25**]
- CT head: There is no acute intracranial hemorrhage DISEASE acute
large major
vascular territory infarction discrete masses mass effect
brain edema DISEASE or
shift of normally midline structures. The ventricles and sulci
are normal in size and configuration. The visualized osseous
structures are unremarkable. The visualized paranasal sinuses
are within normal limits. Incidentally noted is a
faintly-calcified likely sebaceous cyst in the left
paramedian frontovertex scalp soft tissues (2:26-27)Admission Date: [**2137-7-28**] Discharge Date: [**2137-7-31**]

Date of Birth: [**2077-7-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamide Antibiotics) / Latex / Demerol / Codeine /
Penicillins / Propoxyphene

Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Overdose DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname **] is a 60-year-old female with past medical history
significant for Bipolar disorder DISEASE borderline personality
disorder multiple suicide attempts h/o alcoholism PTSD COPD DISEASE
on home O2 breast cancer s/p lumpectomy who presented to ED via
EMS after being found disoriented and wandering around her
housing complex barefoot with 1 empty and 1 full bottle of
clonazepam. She had 1 empty bottle of clonazepam filled [**7-14**]
with 0 tablets and a 2nd bottle of clonazepam filled with 39
pills (filled yesterday so 21 tablets gone). She is supposed to
be taking up to 4 pills per day per [**Month/Year (2) **]. Patient states on
further history that she dropped Admission Date: [**2176-11-17**] Discharge Date: [**2176-11-24**]

Date of Birth: [**2096-10-24**] Sex: M

Service: SURGERY

Allergies DISEASE :
E-Mycin

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
right sided abdominal pain DISEASE

Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy


History of Present Illness:
80 year old male who is well-known to the
surgical service who presented on [**11-13**] with abdominal pain DISEASE and
was found to have evidence of choledocholithiasis DISEASE . He underwent
ERCP on [**11-14**] for delivery of stone and sphincterotomy with
stent
placement. He was discharged yesterday and was pain DISEASE free until
9pm this evening. He describes sudden onset of right sided
abdominal burning DISEASE that is identical in character to the pain DISEASE
that
originally brought him to the hospital several days prior. He
currently denies nausea/vomiting/fevers/chills.

Past Medical History:
Degenerative arthritis DISEASE right knee
gout DISEASE
prostate Ca s/p XRT and Lupron
secondary gynecomastia DISEASE (resolved)
CAD s/p PTCA/2 stents
glaucoma DISEASE
mild hearing impairment DISEASE
non-toxic goiter DISEASE
hypertension DISEASE
hypercholesterolemia DISEASE
hiatal hernia DISEASE with GERD DISEASE
mild irritable bowel syndrome DISEASE
history of intestinal polyps DISEASE (benign)
hemorrhoids

Past Surgical History:
glaucoma DISEASE surgery
b/l cataract DISEASE surgery
Inginal hernia DISEASE '[**70**] (Dr. [**Last Name (STitle) **]
meniscus knee surgery


Social History:
lives with wife runs a business
prior tobacco Admission Date: [**2187-10-29**] Discharge Date:

Date of Birth: [**2135-10-28**] Sex: F

Service: [**Last Name (un) **]


HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 3761**] is a 52-year-old
female who was transferred to the [**Hospital1 190**] in hyperacute fulminant liver failure DISEASE thought
to be secondary to either Bactrim reaction versus
acetaminophen toxicity. She was admitted to the medical
intensive care unit initially and became progressively
obtunded with significant encephalopathy DISEASE requiring
intubation and ventilatory support. Her liver function was
notable for transaminases with an ALT and AST of 9500 and
17500 respectively and worsening hyperbilirubinemia DISEASE . She
became progressively more coagulopathic DISEASE and it was thought
that she was most likely going to need orthotopic liver
transplantation for survival. Given the critical nature of
her illness she was transferred to the transplant surgical
service and to the surgical intensive care unit for further
management. This management initially entailed aggressive
control and monitoring of intracranial pressures in
conjunction with the neurosurgical service. This required
placement of an intracranial bolt DISEASE and aggressive volume
management with the use of hypertonic saline and mannitol.
She continued to receive aggressive cardiopulmonary support
with again as noted full ventilatory support and
vasopressor support for hypotension DISEASE .

COURSE BY SYSTEMS: Neurologically as noted above the
patient required placement of an intracranial bolt DISEASE for ICP
monitoring. Her ICPs had climbed into the high 30s. This was
managed with hyperventilation DISEASE and usage of mannitol and
hypertonic saline. Over the course of the next 4-5 days as
her liver function improved her intracranial pressures
decreased. Her sedation and paralytics were weaned. She had
removal of her intracranial bolt DISEASE on [**2187-11-6**] and it
was noted on subsequent imaging that she had approximately a
4-cm right frontal intracranial hemorrhage DISEASE . This was
followed serially with CT scans and there was no progression
of the bleeding DISEASE . The bleeding DISEASE was thought to be secondary to
her severe coagulopathy DISEASE and thrombocytopenia DISEASE in the setting
of her instrumentation. She was started on Keppra for seizure DISEASE
prophylaxis to finish a 10-day course. On [**2187-11-12**]
the patient was extubated and her neurologic exam was notable
for response to voice and opening of her eyes. She was moving
her left upper extremity and her right lower extremity with
2/5 strength and had minimal movement in her right upper
extremity and left lower extremity not following the
predicted neurologic pattern if this was a deficit DISEASE associated
with her intracranial bleeding DISEASE .

In terms of her respiratory status it is noted that the
patient required full ventilatory support and was extubated
on [**2187-11-12**]. She initially did well but secondary
to what was thought to be pulmonary edema DISEASE required
reintubation on [**2187-11-13**] after failure of noninvasive
positive pressure ventilation. She had some degree of what
appeared to be an ARDS-type reaction DISEASE or transfusion-
associated lung injury DISEASE requiring high amounts of PEEP and
oxygenation during the initial days of her intensive care
unit stay. This resolved over the course of the next several
days with diuresis and supportive therapy.

In terms of her cardiovascular status the patient initially
had blood pressure support with the use of vasopressors in
order to minimize her intravascular volume which was thought
to exacerbate her cerebral edema DISEASE . The vasopressors were
weaned by ICU day 6 and there was no further requirement for
this. There were no significant dysrhythmias DISEASE .

The patient initially thought to most certainly require
liver transplantation spontaneously improved in terms of her
liver function over the course of her 2 weeks in the
intensive care unit. This was evidenced by progressive
ability to metabolize her lactate stabilization of her blood
sugars and autocorrection of her coagulopathy DISEASE . By the time
of her transfer while she continued to have a
hyperbilirubinemia DISEASE her transaminases had completely
normalized. A Dobbhoff feeding tube was in place for post-
pyloric tube feedings. The patient's transaminases were
elevatedAdmission Date: [**2187-10-29**] Discharge Date: [**2187-11-23**]

Date of Birth: [**2135-10-28**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Bactrim

Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Acute liver failure DISEASE

Major Surgical or Invasive Procedure:
Intubation with extubation on [**2187-11-16**]
Hemodialysis
Intracranial bolt DISEASE placement [**10-31**] and removal [**2187-11-5**]


History of Present Illness:
Pt is a 52F with OCD DISEASE (stable recently but h/o OD anorexia DISEASE and
alcohol use in past) ileostomy GERD DISEASE with delayed gastric
emptying who presented to [**Hospital3 3765**] on [**10-28**] with nausea DISEASE
and dizziness DISEASE . There she was initially dx'd with dehydration DISEASE
ARF DISEASE and UTI DISEASE but then found to have ALT of 25370 and of AST
11490 total bili of 2.0 INR of 4.0 Cr of 3.0. She was
transferred to [**Hospital1 18**].
.
She had been having fevers DISEASE for Admission Date: [**2148-8-7**] Discharge Date: [**2148-8-20**]

Date of Birth: [**2094-7-27**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Meningioma DISEASE .

Major Surgical or Invasive Procedure:
Suboccipital craniotomy for resection of tumor DISEASE .

History of Present Illness:
Patient is a 53F seen today in consultation for a Midline
posterior fossa extra-axial mass most likely consistent with a
meningioma DISEASE (DD: dural based met). the lesion is measuring
2.2x1.2cm. She was initialy being seen in the orthopedic clinic
s/p left TKR [**1-/2148**] and complained of a Admission Date: [**2147-11-8**] Discharge Date: [**2147-11-27**]


Service: [**Hospital1 139**].

CHIEF COMPLAINT: Gastrointestinal bleeding bacteremia DISEASE and
fungemia DISEASE .

HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male with multiple medical problems with the past medical
history significant for gastric cancer DISEASE status post resection
with vagotomy prostate cancer DISEASE with likely bony metastasis DISEASE
recurrent aspiration pneumonia DISEASE chronic anemia DISEASE questionable
history of gastrointestinal bleeds DISEASE with several
esophagogastroduodenoscopies in the past showing Candidal
esophagitis DISEASE with nonbleeding fundal polyps DISEASE and dementia DISEASE
thought to be secondary to Alzheimer disease DISEASE . The patient
was admitted to [**Hospital1 69**] on
[**9-30**] with a 30 pound weight loss DISEASE over several
months and acute and chronic mental-status decline and
pneumonia DISEASE . He was treated for his pneumonia DISEASE with Levaquin
and then changed to Azithromycin and sent to Core for
rehabilitation on [**2147-10-4**]. While there the
patient had continued treatment of pneumonia DISEASE and an
esophagogastroduodenoscopy was done on [**10-16**] which
showed esophagitis DISEASE with nonbleeding fundal polyp DISEASE . He had
been started on TPN for unknown number of days which was
being given through a PIC line and on [**10-28**] grew
out MRSA from blood and E. coli from urine. The patient was
started on Cefepime on [**2147-10-30**]. On [**2147-11-4**] the patient was febrile to 102 degrees and repeat blood
cultures at that time showed gram-positive cocci in pairs and
chains. This grew from two sites including the patient's PIC
line. In addition the patient's blood grew out yeast which
had not been speciated at the time of admission. The patient
was started on Vancomycin and Fluconazole on [**2147-11-4**] at [**Hospital1 5042**]. The patient now presents to [**Hospital1 346**] with black-tarry stools which have
been going on for an unknown number of days at [**Hospital1 5042**]. There
was no history of emesis DISEASE or bright red blood per rectum. The
patient's hematocrit was 19 on [**2147-11-6**]. He was
given two units of packed red blood cells at that time with
repeat hematocrit on [**11-8**] still at 19. The patient
was therefore transferred to [**Hospital1 188**] for further evaluation and treatment.

In the emergency department here the patient's temperature
was 100.7 rectally and he was found to be hypotensive DISEASE with a
systolic blood pressure in the 80sAdmission Date: [**2147-11-8**] Discharge Date: [**2147-12-3**]


Service: [**Hospital1 **]

HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year-old Russian
male with a history of gastric and prostate cancer anemia DISEASE
and esophagitis DISEASE who was transferred from the nursing home to
the MICU with a gastrointestinal bleed fungemia DISEASE and
bacteremia DISEASE . He had a very complicated medical course
including treatment for his fungemia DISEASE and bacteremia DISEASE as well
as for aspiration pneumonia DISEASE given his poor mental status and
frequent aspirations. Despite multiple courses of broad
spectrum antibiotics and other supportive measures he
eventually succumbed to one of his aspiration pneumonias DISEASE on
the [**11-2**] and passed away.






[**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**] M.D. [**MD Number(1) 5046**]

Dictated By:[**Name8 (MD) 1552**]

MEDQUIST36

D: [**2147-12-16**] 18:20
T: [**2147-12-20**] 14:46
JOB#: [**Job Number 5048**]
Admission Date: [**2168-7-16**] Discharge Date: [**2168-7-20**]

Date of Birth: [**2106-10-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Purinethol / Remicade

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
BRBPR

Major Surgical or Invasive Procedure:
Upper and lower endoscopy ([**2168-7-17**])


History of Present Illness:
HMED ATTG ADMIT NOTE
.
DATE [**2168-7-16**]
TIME 2300
.
PCP [**Name9 (PRE) **]
GI [**Name9 (PRE) **]
.
61 yo M with Crohn's disease DISEASE on prednisone s/p total colectomy
in [**2147**] complicated by perirectal abscess DISEASE s/p internal drainage
[**9-22**] and newly diagnosed DVT DISEASE [**5-24**] on coumadin who presents to
the ED with BRBPR.
.
Patient reports 16 bloody bowel movements DISEASE yesterday ([**2168-7-15**]).
Went to see PCP ([**Doctor Last Name 2472**]) and INR was 4.7. Patient instructed
to hold coumadin. Went home overnight had multiple bloody
bowel movements DISEASE . This am had 3 episodes of syncope DISEASE where he
awoke on his bathroom floor denies any head trauma DISEASE . Last
bloody BM was around [**1-15**] pm today. No abdominal pain DISEASE (has
chronic rectal pain). No fevers nausea or vomiting DISEASE .
Lightheadedness with standing. Denies any cp or sob. Endorses
mild dysuria DISEASE s/p TURP 4 weeks ago.
.
Went to [**Hospital1 **]-[**Location (un) 620**] ED today and found to have INR 5.4 and Hct of
27 (hct two weeks ago at [**Hospital1 18**] was 36.8). CT abdomen performed
which showed a 15 mm perirectal abscess connected to right
lateral anal fistula DISEASE slightly enlarged from prior MRI in
[**Month (only) 956**] of this year at which time abscess was less organized.
Given 4L of NS. Anoscopic exam performed in ED which showed
moderate maceration of perianal region but no gross bleeding DISEASE .
Heme positive. No fistulas or fissures. Reported that patient
received iv cipro/flagyl however patient states this was never
given.
.
Transferred to [**Hospital1 18**] ED: 97.0 72P 104/76 16 100%RAAdmission Date: [**2184-1-12**] Discharge Date: [**2184-1-16**]

Date of Birth: [**2116-6-9**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Penicillins / Timoptic

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**2183-1-11**] - Coronary bypass grafting x5: Left internal mammary
artery to left anterior descending coronaryAdmission Date: [**2128-9-6**] Discharge Date: [**2128-9-14**]


Service:

HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] with
known mitral valve and 3-vessel disease DISEASE referred for cardiac
catheterization to evaluate his aortic valve.

The patient had never experienced chest pain DISEASE or shortness of
breath in the past. In about [**2116**] the patient had an
exercise treadmill test followed by a cardiac catheterization
which showed 50% proximal left anterior descending artery
60% distal left anterior descending artery 40% proximal
right coronary artery 70% mid right coronary artery and
some degree of mitral regurgitation DISEASE which was subsequently
followed by an echocardiogram in [**2128-7-23**]. The patient
had an exercise tolerance test which showed inferior and
septal ischemia DISEASE with an ejection fraction of 65%.

Cardiac catheterization done on [**2128-8-13**] showed 60%
circumflex proximal 90% distal circumflex 80% proximal
right coronary artery with an 80% distal right coronary
artery 90% posterior descending artery 70% left main and
40% proximal left anterior descending artery and 70% mid
left anterior descending artery.

The patient had an echocardiogram done by a local
cardiologist which showed a question of significant aortic
stenosis that was difficult to assess due to calcification DISEASE .
Catheterization done on the day of admission demonstrated an
aortic valve area of 2.0 cm2 with 16 mmHg of pressure and a
wedge pressure of 8.

PAST MEDICAL HISTORY: (The patient's past medical history is
significant for)
1. Chronic renal insufficiency DISEASE .
2. Cyst on spine at L5Admission Date: [**2178-7-13**] Discharge Date: [**2178-7-16**]

Date of Birth: [**2113-11-13**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Bee Pollens

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
decreased exercise tolerance

Major Surgical or Invasive Procedure:
Minimally invasive mitral valve repair w/annuloplasty band


History of Present Illness:
64 y/o male w/known MVP DISEASE decreasing exercise tolerance followed
by echo. Recently with severe MR DISEASE decreased LVEF.

Past Medical History:
MI
MR/MVP
hepercholesterolemia DISEASE
HTN DISEASE
BPH
s/p tonsillectomy
s/p repair of deviated septum


Social History:
married
never smoked
2 glasses wine/day
no drug abuse DISEASE history

Family History:
mother died of MI at age 55
father died of MI age 62

Physical Exam:
unremarkable pre-op

Pertinent Results:
[**2178-7-16**] 07:20AM BLOOD WBC-8.1 RBC-2.91* Hgb-9.1* Hct-26.6*
MCV-92 MCH-31.3 MCHC-34.2 RDW-14.1 Plt Ct-113*
[**2178-7-16**] 07:20AM BLOOD Plt Ct-113*
[**2178-7-15**] 06:40AM BLOOD Glucose-114* UreaN-22* Creat-0.8 DISEASE Na-136
K-4.4 Cl-105 HCO3-27 AnGap-8

Brief Hospital Course:
Mr. [**Known lastname 2137**] was admitted to the pre-op holding area on [**2178-7-13**]
and taken to the operating room where he underwent a minimally
invasive mitral valve repair w/annuloplasty band.
Post-operatively he was taken to the cardiac surgery recovery
unit. He was weaned from mechanical ventilation and extubated
the evening of surgery. He was transferred to the telemetry
floor on POD # 1. His chest tubes were removed without issue.
He worked with physical therapy to improve his strength and
mobility. He has remained hemodynamically stable and was
discharged home on postoperative day three. He will follow-up
with Dr. [**Last Name (STitle) 1290**] his cardiologist and his primary care
physician as an outpatient.

Medications on Admission:
ASA 81'
Lipitor 80'
Lisinopril 40'
Terazosin 5'
Proscar 5'
Zetia 10'


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet Delayed Release (E.C.) Sig: One (1)
Tablet Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain DISEASE .
Disp:*40 Tablet(s)* Refills:*0*
5. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 weeks: then Q 6 hours prn pain DISEASE .
Disp:*90 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule Sustained Release Sig:
Two (2) Capsule Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule Sustained Release(s)* Refills:*0*
11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
MR s/p min inv MV Repair(#34 annuloplasty band
PMH: MR Admission Date: [**2137-10-31**] Discharge Date: [**2137-11-5**]

Date of Birth: [**2090-7-30**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Morphine / IodineAdmission Date: [**2137-12-25**] Discharge Date: [**2138-1-1**]

Date of Birth: [**2090-7-30**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Morphine / IodineAdmission Date: [**2138-1-24**] Discharge Date: [**2138-2-7**]

Date of Birth: [**2090-7-30**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Morphine / IodineAdmission Date: [**2155-1-2**] Discharge Date: [**2155-1-6**]

Date of Birth: [**2074-12-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
None


History of Present Illness:
80 year old male with h/o COPD CHF DISEASE sent in by PCP to evaluate
hypoxemia DISEASE . His baseline O2 sat is 92% and he was noted to be
78% RA DISEASE at his PCP's office and satting in the 86% 4Ln.c. in the
ED. His CXR with pulmonary congestion DISEASE and RLL pneumonia DISEASE .
Patient states for the past week he has had increasing dyspnea DISEASE
on exertion and also with some dizziness DISEASE and nausea DISEASE with
exertion. Two days prior to admission he states he was sanding
floors with his son wearing a mask and noticed the symptoms to
be more prominent after this. He was initially admitted to the
MICU as he was started on bipap in the ED. In the ICU he
received nebs levofloxacin for his pneumonia DISEASE and diuresed him
with lasix 20mg iv prn. He diuresed 2.4 L off since admission
(24 hrs). He was transitioned quickly off bipap and onto 40%
face mask. ABG on [**1-3**] a.m. 7.34/61/81.
.
He is currently on face mask states his breathing is much more
comfortable. He denies fevers cough chest pain DISEASE abd pain DISEASE leg
swelling DISEASE .

Past Medical History:
COPD DISEASE (last PFTs [**2148**] FEV1/FVC 98% FEV1 55)
Coronary artery disease DISEASE
CHF DISEASE (last echo [**2148**] showed preserved EF Admission Date: [**2158-12-12**] Discharge Date: [**2158-12-19**]

Date of Birth: [**2074-12-4**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Right lower lobe lung nodule

Major Surgical or Invasive Procedure:
[**2158-12-12**]
OPERATIONS:
1. Right video-assisted thoracic surgery (VATS) converted
to right thoracotomy superior segmentectomy of right
lower lobe.
2. Mediastinal lymph node dissection.


History of Present Illness:
Mr. [**Known lastname 5066**] is an 84 year old gentleman who was admitted into
the hospital for surgical management of a right lower lobe mass.
He had a chest CT scan on [**9-14**] that showed a 24 x 28 mm
noncalcified nodule in the superior segment
of right lower lobe. He denied any shortness of breath DISEASE prior to
admission. He did admit to intermittent productive cough DISEASE prior
to admission but no persistent hemoptysis DISEASE . He was admitted
following a right video assisted thoracostomy superior
segmentectomy.

Past Medical History:
COPD DISEASE (last PFTs [**2148**] FEV1/FVC 98% FEV1 55)
Coronary artery disease DISEASE
CHF DISEASE (last echo [**2148**] showed preserved EF Admission Date: [**2159-8-1**] Discharge Date: [**2159-8-7**]

Date of Birth: [**2074-12-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
84M h/o COPD DISEASE dCHF AF AS valve area 0.7 s/p superior
segmentectomy of right lower lobe [**12/2158**] c/o dyspnea DISEASE and cough DISEASE .
.
He was seen initially at [**Hospital 4628**] hospital where sats noted as
high 80s-low 90s on 3L with borderline trop (0.08 which is
[**Hospital1 5075**] reference cutoff). BNP there 734 by report. CXR
there also showed pna but he was not treated there. Given trop
cards at OSH was called however defferred cath since INR 3.5.
Patient was given aspirin steroids and Lasix 40mg (approx 5
hours PTA here). Also had CT head/cspine (both negative) for
fall 1 week ago.
.
On arrival to the ED at [**Hospital1 18**] VS were: 98.6 76 107/57 16
hypoxic in the mid 80s on 3 L but mentating very well and says
he feels relatively well. Lungs had minimal crackles at
bilateral bases.
.
Creatinine 1.2 (baseline 0.9-1.0). CBC 8.5 95% N/37.8/312. UA
was negative. ABG was 7.38/33/132 on NRB 100%. Lactate 1.5.
INR 3.6. Trop was 0.07. CXR consistent with pneumonia DISEASE . ED
resident thinks no ST changes on EKG. Blood cultures were sent.
Patient was discussed with Dr. [**Last Name (STitle) 5076**] who agrees that this may be
pneumonia DISEASE and demand and recommends diuresis and that he may
need cath if does not improve medically. He was given
Levofloxacin 750mg before transfer to ICU.
.
VS on transfer: afebrile (99) 71 117/70s mid 20s 98% on NRB.
BP low to mid 90s when arrived per ED resident. Access is 2
18G IV. Tried titrating down on oxygen a couple of hours ago and
did not tolerate it.
.
On the floor history is obtained from the patient and his son.
They state that since his wife's passing on [**7-14**] he has not been
doing well but denies dyspnea DISEASE or CP during that time. His
daughter moved from [**Name (NI) 108**] and has been living with him and
helping with his medications. He has not missed any medications
nor had any changes except an antidepressant. Patient did have a
fall [**7-21**] when he had been drinking wine and fell over a dining
room chair after he tripped. He was evaluated in the ED the next
day and had neg CT scans. Day prior to admission he was doing
well did yard work and then took 3 cans of prune juice because
of constipation DISEASE . (Children report he takes a lot of OTC stool
meds.) He then had multiple unknown number of episodes of
diarrhea DISEASE yesterday and last night. No fevers DISEASE or chills DISEASE no
cough DISEASE . His son states that the patient told him that he awoke at
4am with pain DISEASE up and down his epigastrum which resolved. No back
pain DISEASE . He then went back to bed and his son found him this
morning at 8:30am sitting in a chair and pale. He was unsteady
and not very responsive. No history of stroke DISEASE or CVA DISEASE .
Currently he states that he feels much improved though has been
dyspneic for the past day since doing the yardwork. No chest
pain DISEASE at all. No swelling DISEASE . Admission Date: [**2159-8-17**] Discharge Date: [**2159-8-22**]

Date of Birth: [**2074-12-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Lethargy hypoxia DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
84M h/o COPD DISEASE dCHF AF DISEASE AS (valve area 0.8cm2) s/p superior
segmentectomy of right lower lobe [**12/2158**] now presenting with
lethargy DISEASE and hypoxia DISEASE .

The patient's family reports increasing lethargy DISEASE for the past 2
days and was found to be hypoxic to the 60's by the VNA. His
daughter had called his PCP [**Last Name (NamePattern4) **] [**8-13**] for weight gain DISEASE but the
decision was made not to increase the Lasix at that time. He
denies shortness of breath chest pain DISEASE fevers/chills cough DISEASE
nausea vomiting abdominal pain DISEASE .

The patient was admitted [**Date range (1) 5081**] for community acquired
pneumonia DISEASE and acute on chronic diastolic CHF. During that
admission the patient was diuresed with Lasix in the MICU for
his acute CHF DISEASE exacerbation. However the patient was called out
to the floor and prior to discharge his Lasix dose was
decreased from 40 mg [**Hospital1 **] to 40 mg every other day for an
elevated bicarb on labs which was attributed to contraction
alkalosis DISEASE . His Spironolactone 25 mg daily was also discontinued
during that admission for unclear reasons. He was treated for
the pneumonia DISEASE with Levofloxacin x7 days and a prednisone burst
and PO2 was 95% on 3L at time of discharge with ambulatory sats
of 85% RA DISEASE unknown ambulatory PO2 on 3L NC. He has been on
supplemental O2 at 2L NC since discharge from his recent
hospitalization.

In the ED initial VS were: 117/57 59 18 93% BIPAP (fiO2
30%)
Exam: shallow breathing Admission Date: [**2130-10-23**] Discharge Date: [**2130-10-24**]

Date of Birth: [**2083-4-10**] Sex: M

Service: SURGERY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hypotension sepsis DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
47M with chronic hepatitis B DISEASE virus associated cirrhosis DISEASE and
delta hepatitis DISEASE suprainfection on the liver transplant list
(baseline MELD 27). EMS was called this morning at 4am for 3
days of worsening abdominal pain DISEASE double vision and weakness.
Upon arrival to his home: HR 100 BP 60/30's O2 sats
84% FS 46. Oriented x 4. Taken to [**Hospital 1474**] Hospital for
stabilization and the transplant center was notified.

At [**Hospital1 1474**] he was started on lactulose Neo-Synephrine
octreotide and midodrine he was intubated started on a D10W
gtt. Once a bed was available he was transferred to the [**Hospital1 18**]
SICU.


Past Medical History:
- congenital Hepatitis B DISEASE
- Hep D positivity
- Cirrhosis DISEASE decompensated by ascites DISEASE and jaundice DISEASE
- Anemia DISEASE
- Psoriasis DISEASE
- Internal hemorrhoids
.

Social History:
Married 2 children 49 worked as social case manager in the
past now works as PCA 8h per week. Has not smoked or drank EtOH
since age of 15. No IVDU.
.
.


Family History:
Mother: HBV DM

Physical Exam:
PE: Neo 0.35 Vaso 2.4 Phenylephrine 1.5 112 91/44 CVP 17 27
96% CMV 100% Admission Date: [**2169-9-1**] Discharge Date: [**2169-9-2**]

Date of Birth: [**2119-6-16**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
none

Major Surgical or Invasive Procedure:
none


History of Present Illness:
The patient is a 50 year old right-handed man presenting
with a few weeks of progressively worsening headache DISEASE . He rarely
has headaches DISEASE (certainly no migraine DISEASE or recurrent severe
headaches DISEASE ) but he started having a headache DISEASE after sustaining a
head injury DISEASE on [**2169-8-3**]. He was driving his car and was
broad-sided on the passenger side causing him to hit the left
side of his head on the side window. He did not lose
consciousness and was not stunned but actually was able to
drive
home (after the rather unpleasant other driver confronted him).
He had no external evidence of head trauma DISEASE . He started having a
bitemporal vertex neck DISEASE and back achy that was predominantly
pulsatile sometimes with a stabbing Admission Date: [**2169-9-11**] Discharge Date: [**2169-9-13**]

Date of Birth: [**2119-6-16**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5084**]
Chief Complaint:
headaches DISEASE

Major Surgical or Invasive Procedure:
[**2169-9-11**]: right temporal craniotomy and resection of lesion


History of Present Illness:
Pt was seen a week prior to this admission for headaches DISEASE . work
up at that time revealed a right temporal lesion. It was
recommended that the patient undergo surgical intervention. He
recommended discharge home and to follow up electively. He now
presents electively for craniotomy and resection

Past Medical History:
[] Neurologic - Possible/questionable seizures DISEASE (lightheaded
fatigue [**Last Name (un) 5083**] vu Admission Date: [**2182-1-19**] Discharge Date: [**2155-2-24**]


Service:

HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old
female with a history of coronary artery disease DISEASE now with
bradycardia DISEASE . He had an episode of dizziness DISEASE when walking
today. His wife took his pulse and noticed it was Admission Date: [**2131-6-17**] Discharge Date: [**2131-6-19**]

Date of Birth: [**2055-3-21**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Hydrochlorothiazide / Norvasc / Zestril / Bactrim Ds

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
inability to swallow

Major Surgical or Invasive Procedure:
EGD and intubation for EGD

History of Present Illness:
76 yo woman with Schatzki's ring s/p dilation in [**2129**] with no
symptoms until 1 mo ago noticed increased time to pass food
below LES (15 minutes) but night prior to presentation developed
inability to pass food/liquids one hour after eating a meal of
fish and chinese noodles.

In the ED: She was given glucagon nitro and zofran. GI was
consulted and requested ICU admission for monitoring planning
EGD for day of admission.

Past Medical History:
hypertension DISEASE
schatzki's ring
anemia DISEASE
s/p hysterectomy
depression DISEASE

Social History:
remote (quit 30-40 years ago) smoking history drinks a glass of
wine with dinner lives with husband retired.

Family History:
noncontributory

Physical Exam:
Flowsheet Data as of [**2131-6-17**] 06:02 PM
Vital SignsAdmission Date: [**2149-2-2**] Discharge Date: [**2149-2-6**]


Service: SURGERY

Allergies DISEASE :
Golytely / Morphine

Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Nausea DISEASE and Vomiting DISEASE
Inability to speak x minutes

Major Surgical or Invasive Procedure:
None

History of Present Illness:
83F with h/o seven prior strokes HTN NIDDM vertigo Bell's
Palsy DISEASE who reports a one day history of nausea DISEASE and vomiting DISEASE
complicated by a brief episode of weakness/altered
responsiveness and inability to speak while sitting on toilet.
This was witnessed by her daughter.

Past Medical History:
history of CADAdmission Date: [**2101-9-7**] Discharge Date: [**2101-9-13**]

Date of Birth: [**2034-11-19**] Sex: F

Service: [**Company 191**]

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF THE PRESENT ILLNESS: The patient is a 66-year-old
woman who has a past medical history dominated by severe
chronic obstructive pulmonary disease DISEASE with OSA DISEASE as well as
CAD and CHF DISEASE . The patient was brought to the emergency
department this AM by her son after she awakened with severe
shortness of breath DISEASE . She was discharged from [**Hospital1 1501**] ([**Hospital1 2670**]
in [**Location (un) 5089**]). Two weeks ago doing well overall with
increased activity level and no chest pain DISEASE or resting
dyspnea DISEASE . She denied recent fever DISEASE of chills DISEASE . She has a cough DISEASE
at baseline.

She was last hospitalized in late [**Month (only) 216**] with fatigue DISEASE and
later chest painAdmission Date: [**2173-12-8**] Discharge Date: [**2173-12-22**]

Date of Birth: [**2103-2-21**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
[**2173-12-17**] - Pericardectomy
[**2173-12-14**] - Cardiac Catheterization
[**2173-12-10**] - Pericardial Window
[**2173-12-9**] - Cardiac Catheterization


History of Present Illness:
The patient is a 70 year old woman with history of PAF
hypertension DISEASE who presents with shortness of breath DISEASE . The patient
has had some sob and cough DISEASE since [**2173-11-15**] when she was admitted
to St E with chest pain DISEASE (sharp substernal pleuritic DISEASE
non-positional) shortness of breath and fatigue DISEASE found to be in
new afib and started on coumadin. At that time an ETT was
negative and she completed a r/o MI. She was hypoxic at that
time requiring 4-6L of nasal cannula. On [**2173-11-18**] she had a CTA
chest that showed small bilateral pleural effusions DISEASE and
bilateral lower lobe atelectasis w/o evidence for PE. On [**2173-11-19**]
she had a tte efAdmission Date: [**2140-7-27**] Discharge Date: [**2140-8-1**]

Date of Birth: [**2085-3-8**] Sex: M

Service: CSU


CHIEF COMPLAINT: This is a 55 year old patient of Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2450**] referred following cardiac catheterization for coronary
artery bypass grafting.

HISTORY OF PRESENT ILLNESS: The patient was admitted to [**Hospital1 1444**] with chest pain DISEASE in [**Month (only) 404**].
He ruled out for a myocardial infarction DISEASE . His pain DISEASE was
thought not to be cardiac at that time. The patient
presented again [**2140-7-16**] with complaints of chest pain DISEASE times
two weeks. Chest pain DISEASE occurred with exertion and
occasionally at rest. He ruled out for a myocardial
infarction DISEASE and did not have any ischemic electrocardiographic
changes. He had a stress test on [**2140-7-18**] stopped because
of chest pain DISEASE and ST depression DISEASE in leads I and V6. His
rhythm was sinus. Nuclear imaging revealed inferoapical
reversible defects with an ejection fraction of 55 percent.
Following stress test the patient had a cardiac
catheterization done on [**2140-7-25**] which revealed two vessel
coronary artery disease DISEASE . Please see catheterization report
for full details. In summary the patient had extremely
short left main. Left anterior descending coronary artery
was diffusely diseased with 50 percent proximal stenosis and
a 95 percent distal lesion. D1 was diffusely diseased. The
circumflex had a 30 percent proximal large obtuse marginal
had 40 percent stenosis at the origin and the right coronary
artery was totally occluded proximally.

PAST MEDICAL HISTORY: Hypertension.

Hyperlipidemia DISEASE .

Diabetes mellitus DISEASE .

Gastroesophageal reflux disease DISEASE .

Unrepaired ventricular septal defect DISEASE .

PAST SURGICAL HISTORY: Rectosigmoid polyp DISEASE removal.

Knee surgery times four.

Appendectomy.

MEDICATIONS ON ADMISSION:
1. Metformin 500 mg twice a day.
2. Prazocin 2 mg twice a day.
3. Metoprolol 100 mg twice a day.
4. Glyburide 5 mg twice a day.
5. Mavik 6 mg p.o. once daily.
6. Protonix 40 mg twice a day.
7. Nifedipine XR 90 mg once daily.
8. Aspirin 81 mg once daily.
9. Niacin 500 mg once daily.


LABORATORY DATA: White blood cell count 6.4 hematocrit
40.8 platelet count 213000. Prothrombin time 12.0 partial
thromboplastin time 26.8 INR 1.0. Urinalysis is negative.
Sodium 132 potassium 4.9 chloride 101 CO2 22 blood urea
nitrogen 26 creatinine 1.3 glucose 210 ALT 25 AST 27
alkaline phosphatase 129 amylase 67 total bilirubin 0.6
albumin 4.0 cholesterol 198.

Chest x-ray showed no radiographic evidence for acute
cardiopulmonary process.

SOCIAL HISTORY: The patient is married. He works for
American Alliance on the loading docks. He is also a driver
for the Israeli Consulate.

HOSPITAL COURSE: As stated previously the patient was a
direct admission to the operating room on [**2140-7-27**]. Please
see the operating room report for full details. In summary
the patient had coronary artery bypass grafting times four
with the left internal mammary artery to the left anterior
descending coronary artery saphenous vein graft to the
obtuse marginal two saphenous vein graft to diagonal
saphenous vein graft to the posterior descending coronary
artery. His bypass time was 78 minutes with a cross clamp
time of 67 minutes. He tolerated the operation well and was
transferred from the operating room to Cardiothoracic
Intensive Care Unit. At that time he was in sinus rhythm at
80 beats per minute. He had a mean arterial pressure of 61
with a PAD of 16. He had Neo-Synephrine at 0.3
mcg/kg/minute insulin at two units per hour and Propofol at
30 mcg/kg/minute. The patient did well in the immediate
postoperative period. His anesthesia was reversed. He was
weaned from the ventilator and successfully extubated. He
remained hemodynamically stable overnight. On postoperative
day number one he was weaned from all cardioactive
intravenous medications. His Swan-Ganz line was discontinued
and his chest tubes were removed. However on a follow-up
chest x-ray the patient was noted to have a pneumothorax DISEASE and
he was therefore kept in the Intensive Care Unit for
pulmonary monitoring. Postoperative day number two the
patient continued to have periods of desaturation DISEASE with little
or minimal activity. His chest x-ray showed a small apical
left pneumothorax DISEASE as well as atelectasis DISEASE . He continued to
have periods where he would desaturate and he was kept in the
Intensive Care Unit again for vigorous chest physical therapy
and pulmonary toilet. On postoperative day number three the
patient continued to do well. With increasing activity and
chest physical therapy he no longer had periods of
desaturation DISEASE and therefore he was transferred to the floor
for continuing postoperative care and cardiac rehabilitation.
At that time his temporary pacing wires were removed. Once
on the floor the patient had an uneventful hospital course
and on postoperative day number four the patient's activity
level had progressed enough that he was considered ready for
discharge to home with visiting nurses. At that time the
patient's physical examination was as follows: Vital signs
showed temperature 98.9 heart rate 82 sinus rhythm blood
pressure 110/56 respiratory rate 18 oxygen saturation 96
percent in room air. Laboratories showed a white blood cell
count 6.1 hematocrit 24.9 platelet count 293000. Sodium
140 potassium 4.5 chloride 103 CO2 30 blood urea nitrogen
21 creatinine 1.2 glucose 105 weight preoperatively 94.9
kilograms and at discharge 100.3 kilograms. On physical
examination neurologically alert and oriented times three
moves all extremities nonfocal examination. Respiratory -
diminished breath sounds in the left base and otherwise clear
to auscultation. Cardiovascular is regular rate and rhythm
S1 and S2 with no murmurs. The sternum is stable. The
incision with staples open to air clean and dry. The
abdomen is soft nontender nondistended with normoactive
bowel sounds. Extremities are warm and well perfused with
one plus edema DISEASE right saphenous vein graft harvest site with
Steri-Strips with large bullae DISEASE underneath the Steri-Strips.

MEDICATIONS ON DISCHARGE:
1. Metoprolol 75 mg twice a day.
2. Ferrous Sulfate 325 mg once daily.
3. Vitamin C 500 mg twice a day.
4. Metformin 500 mg twice a day.
5. Glyburide 10 mg q.a.m. and 5 mg q.p.m.
6. Plavix 75 mg once daily.
7. Aspirin 325 mg once daily.
8. Protonix 40 mg once daily.
9. Niacin 500 mg once daily.
10. Lasix 20 mg twice a day times two weeks.
11. Potassium Chloride 20 mEq twice a day times two
weeks.
12. Dilaudid 2 to 4 mg p.o. q4-6hours p.r.n.


DISCHARGE DIAGNOSES: Coronary artery disease DISEASE status post
coronary artery bypass grafting times four with left internal
mammary artery to the left anterior descending coronary
artery saphenous vein graft to obtuse marginal saphenous
vein graft to diagonal and saphenous vein graft to posterior
descending coronary artery.

Hypertension DISEASE .

Chronic renal insufficiency DISEASE .

Hyperlipidemia DISEASE .

Gastroesophageal reflux disease DISEASE .

Knee surgery times four.

Rectosigmoid polyp DISEASE removal.

Appendectomy.

Diabetes mellitus DISEASE type 2.

CONDITION ON DISCHARGE: Good.

DISCHARGE STATUS: He is to be discharged home with visiting
nurses.

FOLLOW UP: He is to follow-up in the [**Hospital 409**] Clinic in two
weeks follow-up with Dr. [**Last Name (STitle) 2450**] in two to three weeks and
follow-up with Dr. [**Last Name (STitle) **] in four weeks.





[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**] [**MD Number(1) 1715**]

Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2140-8-1**] 16:51:14
T: [**2140-8-1**] 18:20:00
Job#: [**Job Number 5107**]
Admission Date: [**2140-7-15**] Discharge Date: [**2140-7-17**]

Date of Birth: [**2077-7-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest Pain DISEASE

Major Surgical or Invasive Procedure:
Cardiac Catheterization with 3 BMS placed in RCA


History of Present Illness:
Mr [**Known lastname 5108**] is a 62 year-old man with past medical history of
HIV/AIDS hyperlipidemia DISEASE former heavy tobacco use and prostate
cancer DISEASE s/p brachytherapy who was transferred from [**Hospital1 5109**] for STEMI. He reports three hours of substernal chest
pain DISEASE that awoke him from sleep with associated diaphoresis DISEASE . At
[**Hospital1 2436**] EKG showed inferior ST-elevations new from prior in
that system from [**2133**]. He was subsequently transferred to [**Hospital1 18**]
for management of his STEMI.
.
In the cath lab he underwent a Right radial approach. Found
proximal RCA occlusion. Passed wire and baloon inflation with
vagal response requireing 1 dose of atrompine and transient hear
block. Venous sheath placed but no transveous pacer placed. BP's
hung around 100's and response to IVF. Placed 3 BMS in RCA from
proximal to distal. Large vessel. Did not have complete
resolution of STE with some residual [**3-26**] CP that is steadily
improviong. Has ASA and PLavix on board and integrillin x18
hours. Will leave venous sheath in for access. Otherwise stable.



Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes Admission Date: [**2184-10-16**] Discharge Date: [**2184-10-18**]

Date of Birth: [**2131-1-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Etoh withdrawal

Major Surgical or Invasive Procedure:
none


History of Present Illness:
53year-old male with a history of Etoh abuse w/h/o seizures DISEASE
w/withdrawal who presented w/acute etoh intoxication to the ED 1
day PTA. His initial Etoh level was 429 w/last drink day 1 day
PTA. He drink 2 bottles of vodka daily. He was observed
overnight in the ED and appeared to be stable until this AM when
he became hypertensive DISEASE and tachycardic.
.
In the ED he was afebrile BP 162/103 HR 62 O2sat 97%RA. He
received Thiamine folate and Diazepam 5 mg IV x 1(once at 9AM
and once at 10AM) per CIWA scale which was started this AM.
.
ROS: The patient denies any fevers chills DISEASE weight change
nausea vomiting abdominal pain diarrhea constipation DISEASE
melena hematochezia chest pain shortness of breath DISEASE
orthopnea PND lower extremity oedema cough DISEASE urinary
frequency urgency dysuria lightheadedness DISEASE gait unsteadiness
focal weakness vision DISEASE changes headache rash DISEASE or skin changes.



Past Medical History:
-Alcohol abuse h/o withdrawal c/b seizures DISEASE
-Hypertension
-Hepatitis C
-Seizure disorder


Social History:
Smokes a few cigarettes a day x many years. Heavy alcohol
history about 1pint vodka a day now. History IVDU
cocaine/crack use Multiple unprotected female partners.
Homeless living at shelter. Mainly around [**Hospital1 756**] Circle. PCP
is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] [**Hospital 2025**] healthcare for the homeless. Lives
with sister in [**Name (NI) 5110**] when sober. Works in trucking when
sober. He was born in [**State 5111**] worked as a chef. He finished
High School


Family History:
Non-contributory

Physical Exam:
Vitals: T 99.4 : BP 170/110 : HR 80 : RR 17 : O2Sat: 97% RA DISEASE
GEN: anxiouse appearing well-nourished in obviouse distress
HEENT: EOMI PERRL no epistaxis DISEASE or rhinorrhea DISEASE MMM OP Clear
NECK: No JVD carotid pulses brisk no bruits DISEASE no cervical
lymphadenopathy DISEASE trachea midline
COR: RRR no M/G/R normal S1 S2 radial pulses Admission Date: [**2187-8-7**] Discharge Date: [**2187-8-9**]

Date of Birth: [**2131-1-2**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a 56 year old man who has been seen in the Ed on
multiple occasions for frequent falls while intoxicated. He fell
from standing the night of admission and this was witnessed by
friends. [**Name (NI) **] was transferred to [**Hospital1 18**] for evaluation. CT head
showed bilateral SDH. He received Dilantin 1gm IV x1.
Neurosurgery was consulted.


Past Medical History:
1. Alcoholism prior MICU admission for airway protection during

acute intoxication (w/ valium overdose).
2. Hepatitis C.
3. Seizure disorder DISEASE .
4. Status post depressed skull fracture DISEASE in [**2162**].
5. Status post right craniotomy.
6. Status post C4 fracture DISEASE in [**2173**].
7. Status post delirium tremens DISEASE .
8. H/o Aspiration pneumonia DISEASE .
9. Hypertension DISEASE .
10. Right ankle fracture DISEASE .
11. Right arm thrombophlebitis DISEASE .

Social History:
He is homeless and currently staying with friends. [**Name (NI) **] reports
to parole services. He is not currently working. He has a 43
year smoking history currently smokes Admission Date: [**2145-7-7**] Discharge Date: [**2145-7-20**]

Date of Birth: [**2096-7-25**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
R IJ -
intubation -

History of Present Illness:
48M with h/o severe COPD DISEASE (on 2-5L home O2) presenting to OSH
with 2-3wk of increased SOB with cough DISEASE productive of
yellow/white sputum though per his wife no clear fevers DISEASE chest
pain DISEASE n/v abd pain diarrhea rash joint pains DISEASE . His wife notes
poor compliance with his fluid and dietary restriction and
increasing weight from Admission Date: [**2145-7-7**] Discharge Date: [**2145-7-20**]

Date of Birth: [**2096-7-25**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
Right IJ catheter
Intubation for mechanical ventilation
Right PICC line

History of Present Illness:
48 year-old gentleman with severe COPD DISEASE (2-5L home O2) CHF DISEASE and
multiple lengthy prior admissions. Initially presented to OSH
with 2-3 weeks increased SOB and cough DISEASE productive of
yellow/whote sputem but signed out AMA. Admitted to [**Hospital1 18**] MICU
on [**7-7**] with COPD DISEASE flare and treated with solumedrol nebs
cefodoxine/azithromycin and diuretics. Called out from MICU but
then taken back to MICU due to increased dyspnea DISEASE and tachypnea DISEASE .
Intubated and extubated on [**7-14**]. Was net negative 15L across
MICU stays. Also received 7-day course of vanc/zosyn for HAP.
At time of transfer patient was stable. Per ICU patient is still
volume overloaded and needs further diuresis. Patient would be
appropriate for transfer to LTAC bed after the weekend.
On the floor pt was not in any acute distress lying in a
reclining position and requesting to go home tomorrow. When
asked why he said Admission Date: [**2148-12-2**] Discharge Date: [**2148-12-11**]

Date of Birth: [**2084-12-30**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
respiratory distress DISEASE

Major Surgical or Invasive Procedure:
BiPAP

History of Present Illness:
64 yo AA male with HIV/AIDS (VL: 570Admission Date: [**2145-9-6**] Discharge Date: [**2145-9-9**]

Date of Birth: [**2096-7-25**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 5981**] is a 49M with COPD DISEASE (FEV1Admission Date: [**2187-9-3**] Discharge Date: [**2187-9-6**]

Date of Birth: [**2131-10-29**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Beta-Adrenergic Blocking Agents / Shellfish

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
CC:[**CC Contact Info 5995**]
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy

History of Present Illness:
HPI: This is a 55 yo Male with a hx afib HTN DISEASE who had BRBPR
tonight then syncopized in the bathroom. Denies LOC or trauma DISEASE to
his head. The patient denies CP/Abd DISEASE Pain/dyspnea or other
symptoms. Weak x2days and 1 episode of loose stool yesterday.
Does report abdominal cramping DISEASE . No history of prior GIB DISEASE . Never
had colonscopy in past. No NSAID useAdmission Date: [**2182-6-18**] Discharge Date: [**2182-7-2**]

Date of Birth: [**2113-10-31**] Sex: M

Service: [**Hospital Unit Name 196**]

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pressure x 4d

Major Surgical or Invasive Procedure:
Left heart catheterization and taxus stent

History of Present Illness:
68 y/o male with a h/o CAD with a LAD stent placed in [**5-31**] who
was doing well at home s/p cath for approximately one week when
he developed chest pain/pressure lasting four days before he
came to [**Hospital1 18**] ED. Pt's ECG was consistent with reinfarctionAdmission Date: [**2182-2-5**] Discharge Date: [**2182-2-6**]

Date of Birth: Sex: M

Service: Neurosurgery

HISTORY OF PRESENT ILLNESS: Patient was an 84-year-old man
who had a fall at home after a bad headache DISEASE with positive
loss of consciousness DISEASE . 911 was called and he was brought to
the Emergency Room awake and alert. Initial CAT scan of the
head did show a small right subdural hematoma DISEASE as well as left
temporal contusions DISEASE with ventricular blood DISEASE . He was scheduled
for a MRI of the brain when his mental status deteriorated.

Repeat CAT scan of the head showed a larger subdural hematoma DISEASE
on the left side as well as increased contusions DISEASE in the left
temporal region and blood in the fourth ventricle which was
increased.

He was emergently taken to the OR for left craniotomy and
evacuation of a subdural hematoma DISEASE .

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post MI in [**2153**].
2. CABG x4 in [**2169**].
3. Non-insulin dependent-diabetes mellitus DISEASE .
4. GERD.
5. Cataracts DISEASE .
6. Glaucoma DISEASE .
7. Hypertension DISEASE .
8. Osteoarthritis DISEASE .
9. Prostate cancer DISEASE status post TURP in [**2170**].
10. Status post colon resection for adenoma DISEASE .

MEDICATIONS AT TIME OF ADMISSION:
1. Isosorbide.
2. Lasix.
3. Procardia.
4. Naprosyn.
5. Diazepam.
6. Chlorpropamide.

SOCIAL HISTORY: He was not a smoker. Did not drink alcohol.

ALLERGIES: He has allergies DISEASE to dye and shellfish.

HOSPITAL COURSE: Postoperatively he remained intubated.
His vital signs were stable. His left pupil was nonreactive
at 6 mm and the right was 2 mm and nonreactive. He had no
corneal reflexes no gag response or cough DISEASE . He had bloody
drainage from the ventricular drain. He had a poor
prognosis.

On [**2182-2-6**] he had a cold caloric test which was
negative had no response. He continued to be managed in the
Intensive Care Unit. With discussion initially with his wife
and daughter and later with a nephew and after much
discussion the family opted to withdraw care.

On [**2182-2-6**] at 3:20 p.m. the patient expired.



[**Name6 (MD) 742**] [**Name8 (MD) **] M.D. [**MD Number(1) 743**]

Dictated By:[**Last Name (NamePattern1) 5996**]

MEDQUIST36

D: [**2182-4-8**] 12:04
T: [**2182-4-9**] 07:27
JOB#: [**Job Number 5997**]
Admission Date: [**2182-2-5**] Discharge Date: [**2182-2-6**]

Date of Birth: Sex: M

Service: Neurosurgery

HISTORY OF PRESENT ILLNESS: Patient was an 84-year-old man
who had a fall at home after a bad headache DISEASE with positive
loss of consciousness DISEASE . 911 was called and he was brought to
the Emergency Room awake and alert. Initial CAT scan of the
head did show a small right subdural hematoma DISEASE as well as left
temporal contusions DISEASE with ventricular blood DISEASE . He was scheduled
for a MRI of the brain when his mental status deteriorated.

Repeat CAT scan of the head showed a larger subdural hematoma DISEASE
on the left side as well as increased contusions DISEASE in the left
temporal region and blood in the fourth ventricle which was
increased.

He was emergently taken to the OR for left craniotomy and
evacuation of a subdural hematoma DISEASE .

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post MI in [**2153**].
2. CABG x4 in [**2169**].
3. Non-insulin dependent-diabetes mellitus DISEASE .
4. GERD.
5. Cataracts DISEASE .
6. Glaucoma DISEASE .
7. Hypertension DISEASE .
8. Osteoarthritis DISEASE .
9. Prostate cancer DISEASE status post TURP in [**2170**].
10. Status post colon resection for adenoma DISEASE .

MEDICATIONS AT TIME OF ADMISSION:
1. Isosorbide.
2. Lasix.
3. Procardia.
4. Naprosyn.
5. Diazepam.
6. Chlorpropamide.

SOCIAL HISTORY: He was not a smoker. Did not drink alcohol.

ALLERGIES: He has allergies DISEASE to dye and shellfish.

HOSPITAL COURSE: Postoperatively he remained intubated.
His vital signs were stable. His left pupil was nonreactive
at 6 mm and the right was 2 mm and nonreactive. He had no
corneal reflexes no gag response or cough DISEASE . He had bloody
drainage from the ventricular drain. He had a poor
prognosis.

On [**2182-2-6**] he had a cold caloric test which was
negative had no response. He continued to be managed in the
Intensive Care Unit. With discussion initially with his wife
and daughter and later with a nephew and after much
discussion the family opted to withdraw care.

On [**2182-2-6**] at 3:20 p.m. the patient expired.



[**Name6 (MD) 742**] [**Name8 (MD) **] M.D. [**MD Number(1) 743**]

Dictated By:[**Last Name (NamePattern1) 5996**]

MEDQUIST36

D: [**2182-4-8**] 12:04
T: [**2182-4-9**] 07:27
JOB#: [**Job Number 5997**]
Admission Date: [**2106-11-18**] Discharge Date: [**2106-11-27**]

Date of Birth: [**2058-1-23**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Syncope DISEASE

Major Surgical or Invasive Procedure:
[**2106-11-22**] Aortic Valve Replacement utilizing a 27mm CE Perimount
Pericardial Tissue Valve


History of Present Illness:
This is a 48 year old male who was admitted to outside hospital
after syncopal DISEASE episode. Noted to be in rapid atrial fibrillation DISEASE
at that time and converted back to a normal sinus rhythm with
Lopressor and intravenous Cardizem. Echocardiogram revealed
bicuspid aortic valve with severe critical aortic stenosis DISEASE . The
aortic valve area was estimated at 0.6cm2. His left ventricular
ejection fraction was 55-60%. Cardiac catheterization on [**11-17**] confirmed severe aortic stenosis DISEASE . Coronary angiography
revealed clean coronary arteries. Based on the above results he
was transferred to the [**Hospital1 18**] for cardiac surgical intervention.

Past Medical History:
Aortic Stenosis DISEASE Childhood Heart Murmur History of Atrial Fibrillation DISEASE History of Migraine Headaches Horseshoe Kidney DISEASE

Social History:
Denies tobacco and excessive ETOH. Married with children. Works
in construction. Currently lives with his wife.

Family History:
Uncle died suddenly at young age(before 55).

Physical Exam:
Vitals: BP 110/84 HR 71 RR 16 SAT 96% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign left temporal ecchymosis DISEASE stitches
noted below lower lip
Neck: supple no JVD
Heart: regular rate normal s1s2 4/6 systolic ejectiom murmur
which radiated to carotid region
Lungs: clear bilaterally
Abdomen: soft nontender normoactive bowel sounds
Ext: warm no edema DISEASE varicosities noted on left leg
Pulses: 2Admission Date: [**2135-7-15**] Discharge Date: [**2135-7-25**]

Date of Birth: [**2096-2-16**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
[**2135-7-17**] IVC Filter Placed

History of Present Illness:
39 y/o M with PMHx of HTN iritis DISEASE who presented to his PCP's
office with a 2 days of worsening SOB and dizziness DISEASE on standing
after going to the gym.

Patient said on tuesday he noticed left calf Admission Date: [**2170-10-19**] Discharge Date: [**2170-10-27**]

Date of Birth: [**2124-3-6**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Codeine

Attending:[**Known firstname 30**]
Chief Complaint:
Hemoptysis DISEASE

Major Surgical or Invasive Procedure:
Endotracheal Intubation for Respiratory Arrest DISEASE secondary to
sedation


History of Present Illness:
46M h/o alcohol abuse HCV [**3-9**] [**2141**] blood transfusion GERD
admitted with self-reported hemoptysis DISEASE and CP also found to be
alcohol intoxicated. Pt had attended baseball game at which he
drank about 12 beers. Afterwards while walking home pt
suddenly coughed up several tablespoonfuls of blood (per pt's
report to NF he coughed one T of bright red blood). At that
time pt also developed sudden onset L sided CP initiated and
aggravated by breathing accompanied by SOB. Pt later reported
that this pain DISEASE had changed to the R side. Pt noted no other
additional symptoms. Pt then called EMS and was brought to ED.

. ED:
# VS: T 98.1 HR 100 BP 120/76 RR 14 SaO2 96/RA
# Meds: ASA 325 nitroglycerin SL hydralazine metoprolol
( AFib DISEASE RVR) levofloxacin (empiric Rx for PNA). Multiple pain DISEASE
medications (acetaminophen ibuprofen morphine Percocet
hydromorphone). Diazepam per CIWA DISEASE .
# Studies: CXR demonstrated ground glass opacities DISEASE
# Clinical course: Afib DISEASE Admission Date: [**2169-4-5**] Discharge Date: [**2169-4-16**]

Date of Birth: [**2125-10-11**] Sex: F

Service: MEDICINE

Allergies DISEASE :
E-Mycin / Penicillins / Codeine

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
43F H/O IPF DISEASE COPD/Asthma (Multiple Intubations) Current
Smoking Schizoaffective Disorder/Depression with URI symptoms
and dyspnea DISEASE . Patient was well until about one week ago when she
developed rhinorrhea productive cough DISEASE of yellow sputum chills DISEASE
fevers DISEASE mild right ear pain fatigue and then increased dyspnea DISEASE
PND orthopnea DISEASE and decreased exercise tolerance. There was no
rash headache sore throat nausea vomiting diarrhea DISEASE
constipation chest pain DISEASE leg pain DISEASE but has chronic mild
swelling DISEASE . She saw her PCP and had mild improvement with
nebulizers. Her symptoms then worsened and she called EMS.

ED Course: Afebrile. OS85%RA. Peak flow at 250 (baseline of
350). CXR showing perihilar haziness DISEASE with asymmetric hilar
fullness and no definite infiltrate. Started on Levofloxacin
Nebs and admitted to Medicine.

Past Medical History:
1. IPF DISEASE : DIP transthoracic lung bx ([**2166**]) negative
2. COPD/Asthma: Spirometry ([**5-/2164**]) FVC 2.48 (67%) FEV1 1.96
(68%) FEV1/FVC 101% DLCO ([**4-/2163**]) 51% Lung vol ([**4-/2163**]): TLC 64%
FRC 48% RV 49% ERV 47% multiple admissions intubation x 1
[**2163**]
3. Current Smoking
4. Schizoaffective Disorder DISEASE (VH/AH/Paranoia/Olfactory
Hallucinations DISEASE )
5. Depression DISEASE
6. H/O Heavy ETOH Use and DTs
7. TLE (Most Recent Sz five years ago)
8. H/O VRE/MRSA
9. PPD Positive S/P INH
10. H/O Meningitis DISEASE
11. S/P Ex Lap
12. Hyperlipidemia DISEASE
13. DM

Social History:
She lives alone and is a jewlery maker. She currently smokes and
has 30 pack-years. She is detemited to quit smoking today. She
used marijuana cocaine and LSD as a teenager but has not used
drugs since then. She rarely drinks ETOH.

Family History:
No lung or known autoimmune disease DISEASE (such as SLE DISEASE Rh or
Sjogrens). Her father and mother died from MIs DISEASE at ages 55 and
63 resp. Her siblings had MIs DISEASE in their 40s.

Physical Exam:
T100.3 HR115 BP144/69 OS95%2L.
GEN - NAD. SPEAKING IN FULL SENTENCES. EATING.
HEENT - MMM. CLEAR OP. ANICTERIC.
RESP - B/L EXP WHEEZES WITH POOR AIR MOVEMENT. Improving with
peak flows Admission Date: [**2200-12-13**] Discharge Date: [**2200-12-22**]

Date of Birth: [**2141-8-5**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname 6013**] is a 59 year-old male with schizophrenia dementia DISEASE
COPD DISEASE unspecified CHF seizure disorder DISEASE current smoker and
recent pneumonia DISEASE treated with levofloxacin ([**9-17**]) admitted from
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home and Rehab ([**Name8 (MD) 4134**] RNAdmission Date: [**2151-9-21**] Discharge Date: [**2151-9-24**]

Date of Birth: [**2084-12-30**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
nausea/emesis x 2 days

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a 66 yo M w/h/o HIV(last CD4 307 [**2151-9-10**] VL 187
[**2151-9-15**]) HTN DISEASE and severe COPD DISEASE on 3L oxygen at home who
presents w/nausea and emesis DISEASE x 2 days. He notes that he had been
feeling generally well but with constipation DISEASE when he had sudden
onset of nausea DISEASE and emesis DISEASE 2 nights ago. He does not recall what
he was doing. Since then he has been tolerating some food but
has had several episodes of NBNB emesis DISEASE . He notes that he has
not taken any of his medications x 2 days due to the nausea DISEASE . He
also notes that a few days PTA he took one dose of his new
antiretroviral regimen- unsure which pill- and had nausea DISEASE . He
subsequently stopped that regimen and reverted back to his old
regimen. He denies subjective fever/chills. Notes mild diffuse
nonfocal abdominal pain DISEASE which he feels is caused by the nausea DISEASE
and is worse w/eating. He feels that his nausea DISEASE and abdominal
pain DISEASE is c/w severe constipation DISEASE Admission Date: [**2170-7-18**] Discharge Date: [**2170-9-1**]

Date of Birth: [**2109-1-7**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Pollen/Hayfever

Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
Fever DISEASE

Major Surgical or Invasive Procedure:
Thoracentesis

History of Present Illness:
HPI: Patient is a 61 y/o male with cutaneous squamous cell carcinoma DISEASE metastatic to regional lymph nodes currently receiving
XRT with Cisplatin who p/w malaise and febrile neutrophenia DISEASE . Pt
noted malaise for the last couple of days prior to admission
with temp elevated to 101.5 at home. Sx included sore throat
Admission Date: [**2123-6-22**] Discharge Date: [**2123-6-25**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
sepsis DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Age over 90 **] yo M with HTN DISEASE s/p L [**Hospital 6024**] hospital course [**Date range (1) 6025**] for
non-healing infected foot DISEASE ([**1-13**] limb ischemia DISEASE per non-invasives
not on record in OMR) complicated by VRE infection DISEASE requiring
intraoperative debridement and AKA. Patient was discharged to
[**Hospital3 2732**] and Retirement Home in [**Location (un) 55**] where
was in USOH until [**2123-6-21**] when noted chills lethargy DISEASE
low-grade feverAdmission Date: [**2122-5-11**] Discharge Date: [**2122-5-17**]

Date of Birth: [**2038-11-13**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Serevent Diskus / Theraflu Multi Symptom

Attending:[**First Name3 (LF) 832**]
Chief Complaint:
hematuria weakness hypotension DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
83-year old Russian-speaking male with a past
medical history of IDDM asthma AFib DISEASE on coumadin CAD s/p CABG

in [**2105**] diabetic ulcers chronic DISEASE venous stasis DISEASE dematitis/severe

lower extremity edema DISEASE follwoed by vascular service presenting
with hematuria DISEASE shaking in his R arm and hypotension DISEASE and
tachycarida noted in the ED. History was obtained from son and
wife who speak English and are patient's primary caretakers.
[**Name (NI) **] has been declining since around [**Month (only) 1096**]Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-21**]

Date of Birth: [**2038-11-13**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Serevent Diskus / Theraflu Multi Symptom

Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Difficulty urinating urinary retension and edema DISEASE

Major Surgical or Invasive Procedure:
Right heart catheterization [**2122-9-14**]
Peripherally inserted central catheter insertion (PICC) [**2122-9-11**]

History of Present Illness:
This is an 83 year-old Russian-speaking man with diastolic heart
failure CKD DM on insulin asthma atrial fibrillation DISEASE (on
Coumadin) CAD (s/p CABG) h/o colon cancer DISEASE newly diagnosed
breast cancer DISEASE (s/p biopsy 2 weeks ago) presenting with
abdominal distention DISEASE decreased urine output for the past two
weeks with urinary retention DISEASE for the past two days.

His wife noticed increasing edema DISEASE and abdominal girth
approximately 1 month ago. He saw his outpatient cardiologist
who increased his Torsemide dose from 100 to 150 mg PO daily.
Approximately 2 weeks ago his wife again noticed increasing
abdominal girth and firmness as well associated with decreasing
urine output. His cardiologist again increased his Torsemide
dose to 200 mg PO daily on week ago. His edema DISEASE and decreased
urine output continued to progress and he began to develop
scrotal edema DISEASE . Two days prior to admission he was prescribed
metolazone 5 mg to be taken prior to dosing Torsemide. However
he did not receive this medication. At this point he had urinary
retention and his wife brought him to the emergency department.
Review of his medications from OMR revealed that he had been
prescribed Tamsulosin for BPH but he was not taking this
medication.

In the ED initial VS T 97.5 HR 62 BP 99/49 RR 20 SaO2 96% on
RA DISEASE . His creatinine was 2.6 which was an increase above his
baseline of 1.5-2. A Foley was placed Admission Date: [**2142-2-8**] Discharge Date: [**2142-2-9**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Fatigue DISEASE

Major Surgical or Invasive Procedure:
Tranfusion of 2 units of packed red blood cells


History of Present Illness:
88 yo M PMH of pancreatic CA no recent tx in clinic for
survaillence CT scan (which showed no change) mentioned that he
was tired to his oncologist hct was 18.8 down from 28 in
[**Month (only) 359**] sent to ED for eval.

In the ED vitals on presentation were T 97.7 DISEASE BP 153/65 HR 70 RR
24 97%RA. On exam he had no stool in rectal vault but mucous
was guaiac (Admission Date: [**2168-10-20**] Discharge Date: [**2168-10-25**]

Date of Birth: [**2094-10-20**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Demerol / Ativan / Librium / Valium

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Bilateral lower extremity swelling DISEASE and pain DISEASE

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
Mr. [**Known lastname **] is a 73 yo male with CAD s/p CABG x4V in [**2154**] HTN DISEASE
HL A. fib on coumadin type 2 DM with chronic venous stasis DISEASE
and recurrent LLE cellulitis discharged from [**Hospital1 18**]-[**Location (un) 620**] in
[**6-16**] for MRSA cellutis now presenting with increase right
lower extremity warmth swelling redness DISEASE . He reported having a
temperature to 102.4 earlier in the morning. Per wife patient
denied shortness of breath cough chest pain diarrhea DISEASE
abdominal pain dysuria DISEASE .
.
On arrival to the ED patient's vitals were T 98.7 HR 103 BP
74/55 RR 28 O2 sat 89-93% on RA DISEASE . In the ED BP fell to 64/47.
He was given 5L IVF but remained hypotensive DISEASE so was started on
Levophed. He was given Vancomycin and Zosyn to cover
cellulitis DISEASE . He got a CTA which showed no PE but showed
bilateral pneumoniaAdmission Date: [**2111-7-18**] Discharge Date: [**2111-7-25**]

Date of Birth: [**2036-7-23**] Sex: M

Service: CSU


HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with
a history of hypertension diabetes DISEASE and history of syncope DISEASE in
[**2100**] and severe aortic stenosis DISEASE . He presented with
lightheadedness DISEASE for less than approximately one day. The
patient had cardiac catheterization on [**2111-7-16**] to evaluate
aortic valve which showed that the valve diameter was 0.68
cm sq. The patient was to be evaluated for possible valvular
surgery in two weeks at [**Hospital6 1708**] but the
patient has not seen a surgeon since the catheterization. The
patient has baseline dyspnea DISEASE on exertion and the patient
presented with lightheadedness DISEASE but no loss of consciousness DISEASE .
The patient denied chest pain DISEASE and shortness of breath DISEASE at
rest headaches palpitations DISEASE or diaphoresis DISEASE . The patient
also denied fever chills cough nausea vomiting DISEASE bright
red blood per rectum melena DISEASE or hematemesis DISEASE .

PAST MEDICAL HISTORY: History of hypertension DISEASE
hypercholesterolemia diabetes aortic stenosis DISEASE increasing
homocystinemia DISEASE history of syncope DISEASE in [**2100**] hyperthyroidism DISEASE
induced atrial fibrillation DISEASE and benign prostatic hypertrophy DISEASE .

ALLERGIES: No known drug allergies.

MEDICATIONS:
1. Aspirin 81 mg p.o. q day.
2. Lipitor 10 mg p.o. q day.
3. Glucophage 500 mg p.o. q a.m. and 1000 mg p.o. q p.m.
4. Glyburide 10 mg p.o. q a.m. and 5 mg p.o. q p.m.
5. Actos 30 mg p.o. q day.
6. Folate 2 mg p.o. q h.s. and 1 mg p.o. q a.m.
7. Multivitamin.
8. Cardura 4 mg p.o. q h.s.


FAMILY HISTORY: The patient has a brother with a myocardial
infarction DISEASE who underwent coronary artery bypass grafting.

SOCIAL HISTORY: The patient is a cytologist. The patient had
a distant tobacco history rarely drinks alcohol and lives
with his wife.

PHYSICAL EXAMINATION: On arrival the patient's temperature
was 97.9 pulse 58 blood pressure 148/59 respiratory rate
18 100 percent saturation on room air. The patient generally
is an elderly gentleman in no apparent distress. Pupils
equal round and reactive to light. Extraocular movements DISEASE
intact. The patient has no jugular venous distension DISEASE . The
neck is supple without bruits DISEASE . The patient's heart
examination was regular rate and rhythm with apical murmur
and systolic like ejection murmur DISEASE . The patient's chest was
clear to auscultation bilaterally. The patient's abdomen was
soft nontender nondistended with positive bowel sounds. The
patient's extremities had positive edema DISEASE bilaterally.
Neurologically the patient is alert and oriented with a five
out of five strength throughout. The patient's skin had no
lesions or rashes.

LABORATORY DATA: On admission sodium 139 potassium 4.6
chloride 102 bicarbonate 29 BUN 19 creatinine 0.9 glucose
185. The patient's white blood cell count was 3.8 hematocrit
32.7 platelets 148. The patient's urinalysis was negative.
The patient had an echocardiogram in [**3-/2111**] that showed an
ejection fraction of greater than 55 percent with mildly
dilated aortic root mild aortic regurgitation DISEASE and mild
mitral regurgitation DISEASE . The patient had a cardiac
catheterization on [**2111-7-16**] which showed normal coronaries
severe aortic stenosis DISEASE mild mitral regurgitation DISEASE mild
pulmonary hypertension DISEASE and a valvular area of 0.68 cm sq. The
patient's electrocardiogram showed normal axis prolonged PR
without any drop beats and no ST changes from prior
electrocardiogram.

HOSPITAL COURSE: The patient was admitted to the Cardiology
service under the care of Dr. [**Known lastname **]. The Cardiothoracic
Surgery service was consulted for evaluation of aortic valve.
The patient was continued on his home regimen for diabetes DISEASE
and blood pressure was well controlled. The patient was seen
by Cardiac Surgery and was evaluated to have repair of the
severe aortic stenosis DISEASE . The patient underwent aortic valve
replacement with a 23 mm pericardial valve. The patient
tolerated the procedure without any difficulties and was sent
to the Cardiac Surgery Recovery Unit. Please see the dictated
Operative Note for details.

On postoperative day one the patient was extubated and was
also off inotropes. The patient remained in sinus rhythm with
good blood pressure. He was positive for approximately seven
liters since the operation. The patient's saturation was 93
percent on three liters. He was advanced to a cardiac diet.
He remained afebrile. BUN and creatinine were 15 and 0.6. He
received an insulin drip which was weaned. The patient
continued to be on the vancomycin perioperatively. The
patient was started on metoprolol and Lasix. The patient was
seen by Dr. [**Known lastname **] who felt that the patient had a slow sinus
rate and atrioventricular conduction. The patient was seen by
the EP service who felt that there was no current indication
for pacing with high output and felt that the
atrioventricular conduction was good and there was no need to
change the pacer.

On postoperative day two the patient was transferred to the
floor. He remained afebrile with stable vital signs. The
patient's hematocrit was 28.2 and creatinine was 0.8. The
patient's wires were removed. The patient was continued on
Lasix. The Lopressor was increased to 25 mg b.i.d.

On postoperative day three the patient complained of some
left shoulder pain DISEASE . Otherwise he was doing well. The patient
had a rate of 100 and pressure of 108/20 with saturation of
95 percent on two liters. The patient was continued on
intravenous Lasix and metoprolol. The patient was put on pain DISEASE
medications for the left shoulder pain DISEASE and glaucoma DISEASE
medication.

On postoperative day four the patient's heart rate was in
the 90s with good pressure hematocrit of 24.7 and creatinine
of 0.7. The patient was transfused one unit of packed red
blood cells for the low hematocrit.

On postoperative day five the patient had no events
overnight. The patient had a temperature of 100. Otherwise
he had a good heart rate and blood pressure. The patient's
Lasix was changed to p.o. and he was continued on metoprolol.
The patient's hematocrit was 27.4 and potassium was 3.8
which was repleted. Creatinine was 0.7. The patient was
cleared by Physical Therapy and was discharged home.

DISCHARGE DIAGNOSES: Aortic stenosis status post aortic
valve replacement diabetes hyperlipidemia DISEASE high homocystine
level hyperthyroidism DISEASE appendectomy and hydrocele repair.

DISCHARGE MEDICATIONS:
1. Iron 150 mg p.o. q d.
2. K-Dur 20 mEq for six days.
3. Lasix 20 mg for six days.
4. Colace 100 mg p.o. b.i.d.
5. Aspirin 325 mg p.o. q day.
6. Lipitor 10 mg p.o. q day.
7. Zantac 150 mg p.o. q day.
8. Cardura 4 mg p.o. q day.
9. Percocet 1-2 tablets p.o. q 4-6 hours p.r.n. pain DISEASE .
10. Folic acid 2 mg p.o. b.i.d.
11. Glyburide 10 mg p.o. q a.m. and 5 mg p.o. q p.m.
12. Metformin 500 mg p.o. q a.m. and 1000 mg p.o. q
p.m.
13. Actos 30 mg p.o. q day.
14. Metoprolol 25 mg p.o. b.i.d.
15. Motrin 400 mg p.o. t.i.d. p.r.n.
16. Timolol 0.5 percent one drop to the eyes q day.


FOLLOW UP: Please follow-up with Dr. [**Last Name (STitle) 6051**] in one week.
Please have hematocrit checked at that time. Please follow-up
with Dr. [**First Name8 (NamePattern2) **] [**Known lastname **] in two weeks. Please follow-up with
[**Name6 (MD) **] [**Name8 (MD) **] M.D. in four weeks.

DISPOSITION: Home with VNA.

CONDITION ON DISCHARGE: Good.



[**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(2) 5897**]

Dictated By:[**Doctor Last Name 6052**] MEDQUIST36
D: [**2111-7-25**] 12:26:42
T: [**2111-7-25**] 13:11:01
Job#: [**Job Number 6053**]
Admission Date: [**2136-3-14**] Discharge Date: [**2136-3-15**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
transferred from nursing home for respiratory failure DISEASE and
hypotension DISEASE

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
Mr. [**Known lastname 6054**] is a [**Age over 90 **] yo man who was formerly DNR/DNI and Admission Date: [**2165-10-6**] Discharge Date: [**2165-10-11**]

Date of Birth: [**2095-10-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mr. [**Known lastname **] is a 69 year old man with severe CHF DISEASE (EF Admission Date: [**2166-12-18**] Discharge Date: [**2166-12-21**]

Date of Birth: [**2095-10-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
DKA weakness DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
71yoM with a history of DMII (on home Metformin) dilated
cardiomyopathy DISEASE (unclear etiology) EFAdmission Date: [**2150-2-25**] Discharge Date: [**2150-3-1**]

Date of Birth: [**2086-12-19**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
left sided brain lesion

Major Surgical or Invasive Procedure:
[**2-25**] Left Craniotomy for mass resection


History of Present Illness:
[**Known firstname **] [**Known lastname 1852**] is a 62-year-old left-handed man who is here for a
follow up of his left sphenoid meningioma. I last saw him on
[**2149-11-17**] and his head CT showed growth of the left sphenoid
meningioma DISEASE . He is seizure DISEASE free. Today he is here with his
wife
and daughter. [**Name (NI) **] does not have headache nausea vomiting DISEASE
urinary incontinence DISEASE or fall.

His neurological problem began on [**2142-6-22**] when he became
confused and disoriented in a hotel bathroom. At that time he
was visiting his daughter for a wedding. His wife found him
slumped over in the bath tube. According to her his eyes
looked
funny. He could not stand up. His verbal output did not make
sense. He was brought to [**Doctor First Name 1853**] Hospital in Placentia
CA. He woke up 7 to 8 hours later in the emergency room. He
felt very tired after the event. He was hospitalized from
[**2142-6-22**] to [**2142-6-25**]. He had a cardiac pacemaker placement due
to irregular heart rate and bradycardia DISEASE . He also had a head MRI
that showed a less than 1 cm diameter sphenoid meningioma.


Past Medical History:
Cardiac arrhythmia DISEASE as noted above has a
pacemaker in place prostate cancer DISEASE with prostatectomy and
hypertension DISEASE .


Social History:
Lives with his wife. Retired works parttime
driving a school bus.


Family History:
NC

Physical Exam:
Temperature is 97.8 F. His blood pressure
is 150/92. Pulse is 80. Respiration is 16. His skin
has full turgor. HEENT is unremarkable. Neck is supple.
Cardiac examination reveals regular rate and rhythms. His lungs
are clear. His abdomen is soft with good bowel sounds. His
extremities do not show clubbing cyanosis DISEASE or edema DISEASE .

Neurological Examination: His Karnofsky Performance Score is
100. He is awake alert and oriented times 3. There His
language is fluent with good comprehension. His recent recall
is
intact. Cranial Nerve Examination: His pupils are equal and
reactive to light 4 mm to 2 mm bilaterally. Extraocular
movements are full. There is no nystagmus DISEASE . Visual fields are
full to confrontation. Funduscopic examination reveals sharp
disks margins bilaterally. His face is symmetric. Facial
sensation is intact bilaterally. His hearing is intact
bilaterally. His tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: He does not have a drift. His muscle
strengths are [**5-16**] at all muscle groups. His muscle tone is
normal. His reflexes are 0 in upper and lower extremities
bilaterally. His ankle jerks DISEASE are absent. His toes are
down going. Sensory examination is intact to touch and
proprioception. Coordination examination does not reveal
dysmetria. His gait is normal. He can do tandem. He does not
have a Romberg DISEASE .

PHYSICAL EXAM DISEASE UPON DISCHARGE:
non focal
incision c/d/i dissolvable sutures

Pertinent Results:
[**2-25**] CT Head: IMPRESSION:
1. Likely meningioma DISEASE along the greater [**Doctor First Name 362**] of the left sphenoid
bone
measuring 18 mm in diameter unchanged since the most recent
study of [**11/2149**] with reactive bony changes as above.
2. Bifrontal cortical atrophy which has progressed slightly
over the series of studies since the earliest studies of [**2142**].

[**2-25**] CT Head: IMPRESSION:
Expected post-operative changes with the left frontal craniotomy
including
subcutaneous air and soft tissue swelling DISEASE moderate
pneumocephalus DISEASE overlying predominantly the bilateral frontal
lobes and foci of hemorrhage DISEASE in the surgical bed. No evidence
of residual tumor DISEASE on this non contrast CT.

[**2-26**] CXR: FINDINGS: The lung volumes are rather low. There is
moderate cardiomegaly DISEASE without evidence of overt pulmonary edema DISEASE .
No areas of atelectasis DISEASE or pneumonia DISEASE . Right pectoral pacemaker
in situ with correct lead placement.


[**2-28**] Head CT /c contrast: IMPRESSION: Status post left frontal
craniotomy changes with improvement of pneumocephalus DISEASE and stable
3 mm left to right midline shiftAdmission Date: [**2152-2-15**] Discharge Date: [**2152-3-2**]

Date of Birth: [**2084-12-30**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Endotracheal Intubation
Arterial line placement
Internal Jugular line placement


History of Present Illness:
Mr. [**Known lastname 2150**] is a 67M with HIV (Cd4 183 VL 96 copies/mL) and end
stage COPD DISEASE on 3-4L home O2 with a FEV1 of 0.5 who presented to
the emergency room on [**2152-2-15**] with increased shortness of breath DISEASE . Three days prior to presentation he developed nasal
congestion DISEASE and rhinorrhea DISEASE which made it difficult for him to use
his supplemental oxygen at home. He had subjective fevers DISEASE and
chills DISEASE but did not check his temperature. He had minimal cough DISEASE
productive of dark yellow sputum. He was feeling more short of
breath despite increasing oxygen use. He was concerned about
pneumonia DISEASE and presented to the emergency room.
.
In the emergency room his initial vitals were T: 98.1 HR: 86 RR:
107/72 RR: 22 O2: 100% on RA DISEASE . He had a chest xray which showed
significant hyperinflation but no acute cardiopulmonary process.
He received levofloxacin 750 mg IV x 1 duonebs solumedrol 125
mg IV x 1 and aspirin 81 mg. He was initially admitted to the
floor.
.
While on the floor he was started on azithromycin solumedrol
125 mg IV TID albuterol and ipratropium nebulizers. He did well
on hospital day 1 but overnight his shortness of breath DISEASE
worsened. He had a repeat CXR which was similar to priors. He
had an ABG on a non-rebreather which was 7.37/57/207/34. He had
increased work of breathing and asked to be placed on Admission Date: [**2176-11-21**] Discharge Date: [**2176-11-26**]

Date of Birth: Sex: M

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old
male with a past medical history of diabetes hypertension DISEASE
and deep venous thrombosis DISEASE presenting with a fever DISEASE and lower
extremity pain DISEASE times one day.

In the Emergency Department the patient was noted to have a
fever DISEASE and hypotension DISEASE . He received 6 liters of intravenous
fluids Ancef and Unasyn and was transferred to the Medical
Intensive Care Unit.

PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus DISEASE .
2. Hypertension.
3. Bilateral deep venous thrombosis DISEASE .
4. High cholesterol.
5. Anal fissure.
6. Thalassemia.

MEDICATIONS ON ADMISSION: Actos Glucophage atenolol
aspirin and Lipitor.

ALLERGIES: ERYTHROMYCIN.

SOCIAL HISTORY: No alcohol. No tobacco. No drug use.

FAMILY HISTORY: Mother with diabetes DISEASE .

PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination the patient had a temperature of 103.5 his
heart rate was 112 his blood pressure was 109/50 his
respiratory rate was 20 and his oxygen saturation was 100%
on 2 liters. In general he was alert and oriented times
three. In no acute distress. Head eyes ears nose and
throat examination revealed the sclerae were anicteric. The
oropharynx was clear. No neck stiffness DISEASE . Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. No murmurs. The lungs
were clear to auscultation bilaterally. The abdomen was
soft nontender and nondistended. Positive bowel sounds.
Extremities revealed right lower extremity venous changes.
Pain DISEASE the medial thigh to the calf. No rash DISEASE . Neurologic
examination revealed cranial nerves II DISEASE through XII were
intact. Sensation and strength were [**6-10**]. Distal pulses were
2Admission Date: [**2179-8-9**] Discharge Date: [**2179-8-17**]

Date of Birth: [**2133-5-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
E-Mycin

Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
RLE Cellulitis/Code Sepsis DISEASE

Major Surgical or Invasive Procedure:
Central Line Placement


History of Present Illness:
46 yo M with HTN DM2 DISEASE who presents to the ED with 1 day of
right lower extremity warmness. Pt and wife say that yesterday
he was feeling fatigued and Admission Date: [**2173-12-31**] Discharge Date: [**2174-1-8**]


Service:

HISTORY OF PRESENT ILLNESS: This is an 85-year-old woman
with history of hypertension DISEASE who was admitted to an outside
hospital prior to being admitted to [**Hospital1 190**] on [**12-31**]. At the outside hospital the patient
had investigation for two month history of abdominal pain DISEASE
which showed mainly epigastric. This work-up included
abdominal CT which showed thickened duodenal valve 2 cm
adrenal mass question of colon lesion DISEASE consistent with
intermittent intestinal obstruction DISEASE . Her CEA at the outside
hospital was 41. She was admitted to [**Hospital1 190**] on [**12-31**] with worsening of the abdominal
epigastric pain nausea vomiting DISEASE for two days. In the
hospital the patient had work-up which included CT angiogram
due to abnormal EKG initially which revealed pulmonary
embolism DISEASE and patient had been started on Heparin. Her
initial EKG revealed T wave inversion at V2 and V6 plus ST
depression DISEASE so she was also admitted for rule out MI. CT also
revealed dilated common bile duct DISEASE up to 18 mm. Her
hematocrit on admission was 29.0 and drifted to 22.5 on
[**1-1**]. She had two episodes of coffee ground emesis DISEASE on
[**1-1**] became hypotensive DISEASE and bradycardic and acute EGD was
performed which revealed grade 3 esophagitis DISEASE in the lower
third ulcer DISEASE in the stomach body and antrum blood in the
stomach and anterior vault. There was large oozing DISEASE clot in
the duodenal bulb. Hemostasis was achieved with Epinephrine
injection. Anticoagulation was discontinued and patient was
started on Protonix drip and had been transferred to medical
Intensive Care Unit due to hypotension DISEASE and active bleeding DISEASE .
The same day she had IVC filter placed which was done on
[**1-2**]. The patient received two units of FFP followed by 6
units of packed red blood cells. On [**1-2**] the patient was
transferred back to the medicine floor and on [**1-3**] she had a
second EGD done due to hematocrit of 33.6 which drifted to
32.2. EGD at that time revealed esophagitis ulcers DISEASE in the
antrum which were injected with Epinephrine and also
posterior bulb injection and thermal therapy a large
inferior posterior duodenal ulcer DISEASE with oozing DISEASE refractory to
injection. For this reason the patient underwent angiography
revealing the source of bleeding DISEASE and underwent duodenal gastric artery embolization DISEASE . She was then transferred with
additional two units packed red blood cells. Her hematocrit
after transfusion went to 38.5 on [**1-4**].

Other studies during the hospital course included chest x-ray
which revealed widened mediastinum secondary to tortuous and
dilated thoracic aorta DISEASE and bibasilar atelectasis DISEASE . CTA
revealed moderate intra and extrahepatic ductal DISEASE dilatation
left pulmonary artery embolism DISEASE and left adrenal mass.
Ultrasound of the lower extremities revealed no DVT DISEASE KUB
revealed no obstruction and chest x-ray on [**1-5**] revealed
bilateral small pleural effusion DISEASE with consolidation of the
lower lobe presenting either atelectasis DISEASE or infection DISEASE . She
was transferred to general medicine floor on [**1-5**].

PAST MEDICAL HISTORY: Includes hypertension non-insulin DISEASE
dependent diabetes mellitus coronary artery disease DISEASE status
post MI status post CCY.

MEDICATIONS: At home Zocor Aspirin Atenolol Isosorbide
Meclizine Pravachol Imdur. On transfer Protonix 40 mg
[**Hospital1 **] Lopressor 50 mg [**Hospital1 **] Accolate 20 mg [**Hospital1 **] Pravachol 20 mg
q d Tylenol 650 mg qid Nephrocaps Captopril 12.5 mg tid
Magnesium Oxide 400 mg [**Hospital1 **] Ambien prn.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: The patient denies smoking or alcohol.

FAMILY HISTORY: Significant for father who died from
esophageal cancer DISEASE and mother from stroke DISEASE .

PHYSICAL EXAMINATION: On admission to medicine temperature
98.0 heart rate 72 respiratory rate 20 blood pressure
164/78 98% on one liter. Patient in no acute distress
pale. HEENT: Revealed no icterus DISEASE pupils are equal round
and reactive to light and accommodation oropharynx clear
mucus membranes are dry. Neck no JVP. Cardiac S1 and S2
regular rate and rhythm no murmur. Lungs CTA. Abdomen
soft nontender non distended with positive bowel sounds DISEASE .
Extremities with no edema DISEASE and normal peripheral pulsation.

HOSPITAL COURSE: This is an 85-year-old woman with history
of hypertension non-insulin DISEASE dependent diabetes mellitus DISEASE
coronary artery disease DISEASE now admitted with a two month
history of epigastric pain DISEASE . She was found to have peptic
ulcer disease DISEASE with massive GI bleeding DISEASE requiring twice EGD
injection with Epinephrine embolization of gastroduodenal
artery. Her detailed hospital course is described in the
HPI. After transfer to medicine service she remained stable
and her hematocrit remained stable as well.

LABORATORY DATA: Hematocrit on admission 24.4 32.9 on
[**1-2**].4 on [**1-3**].5 on [**1-4**].2 on [**1-5**].
Hemoglobin 11.5 on [**1-5**] white blood count 9.8 platelet
count 124000 INR 1.0 sodium 143 potassium 3.3 chloride
101 CO2 30 BUN 17 creatinine 1.0 ALT AST total
bilirubin within normal limits CK 188 148 154 C troponin
negative Cortisol 53 CEA 25 H. pylori negative. Calcium
phosphorus magnesium within normal limits.

DISCHARGE DIAGNOSIS:
1. Peptic ulcer disease DISEASE .
2. Upper GI bleed.
3. Status post pulmonary embolism DISEASE .
4. Status post IVC filter.
5. Hypertension.
6. Anemia.
7. Non-insulin dependent diabetes mellitus DISEASE .
8. Coronary artery disease DISEASE .

DISCHARGE MEDICATIONS: Protonix 40 mg po bid Clarithromycin
500 mg po bid for 14 days Amoxicillin 1 gm po bid for 14
days KCL 20 mEq po q d Captopril 12.5 mg po tid Magnesium
Oxide 400 mg po bid Neutra-Phos one pack po qid Pravachol
20 mg po q p.m. Accolate 20 mg po bid Lopressor 50 mg po
tid.

Patient will be discharged to a rehabilitation hospital in
stable condition.




[**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 1197**]

Dictated By:[**Last Name (NamePattern1) 6063**]
MEDQUIST36

D: [**2174-1-7**] 08:32
T: [**2174-1-7**] 11:05
JOB#: [**Job Number 6064**]
Admission Date: [**2174-6-8**] Discharge Date: [**2174-6-11**]


Service: [**Location (un) **] General Medicine Firm

HISTORY OF PRESENT ILLNESS: 85-year-old woman with history
of metastatic pancreatic biliary cancer DISEASE who presents from
home with 3-4 days of malaise with weakness. Her last bowel
movement was three days prior to admission. She has
decreased urine output the prior two days no chest pain DISEASE
although she does have some shortness of breath and abdominal DISEASE
pain DISEASE over the past few days. She feels weak and has diffuse
aches DISEASE and pains DISEASE . She has a history of GI bleed DISEASE in the
setting of anticoagulation for pulmonary embolism DISEASE . In
[**2174-2-18**] she underwent embolization of a duodenal artery
by interventional radiology at that time. She has a large
pancreatic mass DISEASE requiring gastrojejunostomy done by Dr.
[**Last Name (STitle) **] because of stricture/obstruction. She has not
noticed any melena DISEASE or bright red blood per rectum. In the
Emergency Room she was with blood pressure 80/60 hematocrit
12.5 received one liter of normal saline one unit of packed
red blood cells. EGD showed bleeding DISEASE of a pancreatic mass DISEASE in
the stomach. Patient and family wanted to proceed with IR
intervention.

PAST MEDICAL HISTORY: Metastatic pancreatic cancer DISEASE biliary
cancer with mets DISEASE to the liver diagnosed in [**2-19**] during GJ
tube placement with liver biopsy. Pulmonary embolism DISEASE status
post IVC filter placement in [**2173-12-18**]. GI bleed in the
setting of anticoagulation for pulmonary embolism DISEASE .
Hypertension DISEASE . Diabetes mellitus DISEASE type 2 coronary artery
disease status post MI status post cholecystectomy chronic
obstructive pulmonary disease DISEASE .

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS: Calcium carbonate 1 gm tid Captopril 150 mg po
tid Reglan 10 mg po tid Metoprolol 50 mg po bid Zantac 150
mg po bid Ativan .25 mg po q 8 hours prn Darvocet two
tablets po prn OxyContin 20 mg po bid prn Ambien 5 mg po q
h.s. prn Glucotrol 5 mg po bid.

SOCIAL HISTORY: No tobacco or alcohol use she immigrated 9
years ago.

FAMILY HISTORY: Father had esophageal cancer DISEASE mother had a
stroke DISEASE brother has lung cancer DISEASE .

PHYSICAL EXAMINATION: On admission is notable for
temperature 97.7 pulse 79 blood pressure 94/63
respirations 15. 100% sat on room air. In general alert
and oriented times three no acute distress Russian
speaking. HEENT: Pupils are equal round and reactive to
light extraocular movements DISEASE intact oropharynx clear right
IJ line in place no lymphadenopathy DISEASE . Heart tachycardic no
murmurs rubs or gallops. Chest is clear to auscultation
bilaterally no wheezes or rales. Abdomen soft nontender
active bowel sounds DISEASE positive ascites DISEASE . Extremities no
edema DISEASE dorsalis pedis DISEASE pulses Admission Date: [**2100-11-8**] Discharge Date: [**2100-11-14**]

Date of Birth: [**2021-9-7**] Sex: F

Service: CSU


Ms. [**Known lastname 174**] is a direct admission to the operating room for
aortic valve surgery. She was seen in preadmission testing
prior to her scheduled surgery. At the time of visit in
preadmission testing the patient's physical exam is as
follows.

CHIEF COMPLAINT: Asymptomatic patient.

HISTORY OF PRESENT ILLNESS: A 79-year-old woman with known
AS x 9 years followed by serial echoes the last echo with
worsening aortic stenosis DISEASE and a diminishing aortic valve
area referred for cath and followed by aortic valve
replacement. The patient had an echo done in [**2100-8-29**]
that showed an EF of 60 percent with an aortic valve area of
0.9 and a peak gradient of 96 and a mean gradient of 60
with mild LVH DISEASE 1 plus AI and 1 plus TR. She had a cardiac
cath done [**10-5**] that showed an aortic valve gradient of
56 with an aortic valve area of 0.5 cm2 an EF of 56
percent RCA 40 percent left main 20 percent and an LAD 30
percent lesion.

PAST MEDICAL HISTORY: Hypertension DISEASE .

Aortic murmur DISEASE .

Hiatal hernia DISEASE .

GERD.

Diverticulosis.

Hernia repair in [**2034**].

Cataract DISEASE surgery in [**2096**].

D and C in [**2071**].

Drainage of a thyroid cyst DISEASE approximately 10 years ago.

MEDS AT ADMISSION:
1. Cardizem CD 240 once daily.
2. Hydrochlorothiazide 12.5 once daily
3. Lipitor 10 once daily.
4. Niferex 150 once daily.
5. Calcium.
6. Glucosamine.
7. Metamucil.


ALLERGIES: The patient states environmental allergies DISEASE as
well as codeine although her reaction is simply confusion DISEASE .

FAMILY HISTORY: Mother died of CAD in her 70s. Father died
of CAD late in life.

SOCIAL HISTORY: She lives with her husband. She denies
tobacco use. Occasional alcohol use. No other recreational
drug use.

REVIEW OF SYMPTOMS: Noncontributory.

PHYSICAL EXAM DISEASE : VITAL SIGNS: Heart rate 86 blood pressure
124/80 respiratory rate 20 height 5 feet 0 inches weight
138 pounds. GENERAL: Sitting up in chair no acute
distress. SKIN: Warm dry DISEASE and intact. No lesions. HEENT:
Pupils equally round and reactive to light. Extraocular
movements intact. Neck is supple with no JVD and no bruits DISEASE
but she does have a radiated murmur. Chest is clear to
auscultation bilaterally. Heart regular rate and rhythm with
a IV/VI systolic ejection murmur. Abdomen is soft
nontender nondistended with normoactive bowel sounds DISEASE .
Extremities are warm and well-perfused with 1-2 plus edema DISEASE
right greater than left. VARICOSITIES: None.
Neurologically alert and oriented x 3. Nonfocal exam.
PULSES: Femoral 2 plus bilaterally. Dorsalis pedis 1 plus
bilaterally. Posterior tibial 1 plus bilateral. Radial 2
plus bilaterally.

Carotid ultrasound showed less than 40 percent stenosis
bilaterally.

LABS: White count 4.5 hematocrit 32 platelets 234 PT
12.8 INR 1.0 sodium 139 potassium 3.2 chloride 100 CO2
28 BUN 16 creatinine 0.8 glucose 122 ALT 13 AST 22 alk
phos 82 amylase 78 total bili 0.5 albumin 4.0 hemoglobin
A1C 5.1. Chest x-ray showed no CHF DISEASE or pneumonia DISEASE .

HOSPITAL COURSE: On [**11-8**] the patient was directly
admitted to the operating room where she underwent an aortic
valve replacement with a number 23 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
tissue valve. Her bypass time was 142 minutes with a
crossclamp time of 102 minutes. She tolerated the operation
well and was transferred from the operating room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient was in a normal sinus rhythm at 85 beats per
minute with a mean arterial pressure of 67 and a CVP of 15.
She had propofol at 20 mcg/kg/min and Neo-Synephrine at 0.15
mcg/kg/min.

The patient did well in the immediate postoperative period.
Her anesthesia was reversed. She was weaned from the
ventilator and successfully extubated. Throughout that
period she remained hemodynamically stable as she did
throughout the operative day. However she did require a
Nipride drip to maintain a blood pressure between 100 and
110.

On postoperative day 1 the patient continued to be
hemodynamically stable. She was begun on oral medications
and weaned off of her Nipride drip. Additionally her chest
tubes were removed and she was transferred to the floor for
continuing postoperative care and cardiac rehabilitation.
Once on the floor the patient had an uneventful hospital
course. Her activity level was increased with the assistance
of the nursing staff as well as physical therapy.

On postoperative day 3 her temporary pacing wires and her
Foley catheter were removed. Over the next 2 days her
activity level was further advanced with nursing and physical
therapy assistance and on postoperative day 6 it was
decided that the patient was stable and ready to be
discharged to home.

DISCHARGE VITALS: Temperature 98.3 heart rate 81--sinus
rhythm blood pressure 128/66 respiratory rate 22 O2 sat 94
percent on room weight preoperatively 63 kg at discharge
60.1 kg.

LAB DATA: Hematocrit 29.4 sodium 142 potassium 3.5
chloride 102 CO2 34 BUN 16 creatinine 0.8 glucose 98.

DISCHARGE PHYSICAL EXAM DISEASE : NEURO: Alert and oriented x 3.
Moves all extremities. Follows commands. Nonfocal exam.
RESPIRATORY: Lungs clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm S1 S2 with no murmur.
Sternum is stable. Incision with Steri-Strips open to air
clean and dry DISEASE . Abdomen is soft nontender nondistended with
normoactive bowel sounds. Extremities are warm and well-
perfused with no edema DISEASE .

Th[**Last Name (STitle) 1050**] is to be discharged to home with visiting nurses.
She is to have follow-up with Dr. [**Last Name (STitle) 6073**] in [**3-2**] weeks and
follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks. Additionally she
is to have follow-up with her primary care doctor [**First Name (Titles) **]
[**Last Name (Titles) 5887**] once she returns to [**State 5887**].

DISCHARGE DIAGNOSES: Status post aortic valve replacement
with a number 23 [**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve.

Hypertension DISEASE .

Gastroesophageal reflux disease DISEASE .

Diverticulosis.

Hernia repair.

Cataracts DISEASE .

DISCHARGED MEDICATIONS:
1. Metoprolol 50 mg [**Hospital1 **].
2. Colace 100 mg [**Hospital1 **].
3. Aspirin 325 once daily.
4. Percocet 5/325 1-2 tabs q 4-6 hr prn.
5.
Atorvastatin 10 mg once daily.
6. Niferex 150 mg once daily.




[**Doctor Last Name **] [**Last Name (Prefixes) **] M.D. [**MD Number(1) 1288**]

Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2100-11-15**] 17:55:55
T: [**2100-11-16**] 10:57:54
Job#: [**Job Number 6074**]
Admission Date: [**2188-7-19**] Discharge Date: [**2188-7-22**]


Service:

HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
male who underwent a screening endoscopy and colonoscopy on
[**2188-7-18**]. During the procedure polypectomy was performed on
a polyp DISEASE seen in the left ascending colon. The patient was
discharged home and on the morning of admission developed
brisk bright blood per rectum and syncope DISEASE when he stood up
from his bed. He presented to the Emergency Department at
which time he was found to be hypotensive DISEASE with a systolic
blood pressure in the 60's. He was immediately resuscitated
for hypovolemic shock DISEASE .

The patient also underwent nasotracheal intubation in the
Emergency Room for airway protection.

PAST MEDICAL HISTORY: Significant for prostate cancer DISEASE basal
cell carcinoma colonic polyp hiatal hernia DISEASE
gastroesophageal reflux disease DISEASE .

PAST SURGICAL HISTORY: Significant for bilateral inguinal
hernia DISEASE repairs. Status post XRT for prostate cancer DISEASE and a
previous transurethral resection of prostate.

MEDICATIONS ON ADMISSION: None.

ALLERGIES: None.

SOCIAL HISTORY: There is no history of tobacco or ETOH use.

PHYSICAL EXAMINATION: The patient was intubated and sedated.
Heart rate was 90Admission Date: [**2176-10-19**] Discharge Date: [**2176-10-22**]

Date of Birth: [**2102-3-3**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Zosyn

Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Ms. [**Known lastname 6083**] is a 74 y/o female with a history of COPD DISEASE dCHF CAD
s/p MI in [**2167**] who presents with intermittent confusion DISEASE since
thursday and shortness on breath since the night PTA. She used
her nebs at home without relief. According to her daughter she
has been requiring more pillows at night but denied any PND.
Denies fevers chills cough nausea vomiting chest pain DISEASE . Does
note left arm pain DISEASE which is her anginal DISEASE equivalent intermittent
since thursday. She denied any sick contacts however notes that
she has not been compliant with a low salt diet. She notes that
her weight has not changed.
.
In the ED initial VS were: 97.8 96 181/61 20 89% RA DISEASE . EKG showed
sinus 81 [**Last Name (LF) **] [**First Name3 (LF) **] dep I AVL DISEASE V5-6 (Admission Date: [**2176-12-16**] Discharge Date: [**2177-1-5**]

Date of Birth: [**2102-3-3**] Sex: F

Service: SURGERY

Allergies DISEASE :
Zosyn / Penicillins / Dilantin

Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
AAA

Major Surgical or Invasive Procedure:
[**2176-12-16**]
1. Bilateral common femoral artery cutdown.
2. Right common iliac artery and external iliac artery
stent grafts with angioplasty.
3. Abdominal aortogram.
4. Aorta right uniiliac endograft.
5. Right iliofemoral bypass with Dacron.
6. Right to left femoral-to-femoral bypass graft with
polytetrafluoroethylene (PTFE).
7. Coil embolization of the right hypogastric artery.
8. Coil embolization of the left common iliac artery.

History of Present Illness:
74F with a known 5.3x7.2cm AAA presented to her PCP for [**Name Initial (PRE) **] non
contrast CT screening test secondary to recent weight loss DISEASE which
revealed enlargement of the aneuysm DISEASE . She was referred to Dr.
[**Last Name (STitle) **] for further evaluation and contrast enhanced CT revealed a
6.6x9.0cm aneurysm DISEASE . Given the findings of enlargement COPD DISEASE and
irregular shape she was at a high risk for rupture DISEASE . Also
secondary to her comorbidities she was not an open repair
candidate. She was then evaluate for endovascular repair for
which her imaging was sent for three-dimensional reconstruction
and a suitable endovascular option was found. She agreed to the
procedure given the risks of renal failure DISEASE requiring dialysis
respiratory failure DISEASE and death DISEASE .

Past Medical History:
- Coronary artery disease DISEASE - negative MIBI in [**8-8**]. s/p MI in
[**2167**] and has Admission Date: [**2122-3-3**] Discharge Date: [**2122-3-7**]

Date of Birth: [**2073-6-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Sulfonamides / Hydrochlorothiazide / Lipitor / Zocor /
Glucophage / Neurontin / Lasix / Lyrica / Tylenol/Codeine No.3

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
hyperkalemia ARF DISEASE

Major Surgical or Invasive Procedure:
CTA of the chest (showed evidence of Pneumonia DISEASE )
CT of the head (normal)


History of Present Illness:
48 year old female with hx of DMII now presenting to ER due to
outside blood work yesterday showeing K of 6.0 at her annual
physcial and an elevated Cr to 1.7. It was rechecked today and
still elevated depsite today stopping her ACEI and aldactone.
She was instructed to go the ER. While in ER pt felt like her
sugar was low and had a fs of 56 she was given detrose and BS
improved to 87. She reports that she previously had bs always
Admission Date: [**2177-4-14**] Discharge Date: [**2177-4-18**]

Date of Birth: [**2098-11-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Hypoxia
Posterior hip dislocation DISEASE

Major Surgical or Invasive Procedure:
Reduction of left posterior hip dislocation DISEASE
PICC line insertion

History of Present Illness:
78M with hx of CABG in [**2168**] CAD DM hx of hip frequent
dislocation DISEASE of artificial L hip tripped over rug in apartment
and fell no Head strike or LOc. He felt hip [**Doctor Last Name **] out. In the ED
initial VS were:97.3 108 144/75 16 no O2 sat recorded 3L
NC(recorded).However resident noted patient to be tachypneic DISEASE at
35 hypoxic to 50. Patient did note several hours of shortness of
breath today upon further questioning. CXR showed R pulmonary
edema DISEASE vs infiltrate placed on NRB then sats to mid90s-100. A
CT scan was negative for PE but did show right sided pneumonia DISEASE
possible aspiration. Patient noted to have elevated lactate 4.4.
WBC 2.8 with N:59.5 L:33.2 M:5.4 E:0.9 Bas:1.0.
Vanc/Zosyn/Levoflox given. Trop of 0.05. EKG: sinus 92 NA IV
conduction delay ST depression DISEASE I and aVL.
.
In ED Ortho consulted and patient had procedural sedation with
with fent (100)/versed (4) hip successfully reduced in ED.
Reversed sedation with flumazenil (0.2)/narcan (2) Got 2L IV
fluids for the lactate.
.
On arrival to the MICU patient's VS. 97.7/ 81/112/69/13 100%
NRB. On recheck 91% on RA DISEASE . 97% on 2L. patient denied any Chest
pain/SOB. Feels very well and is surprised to be admitted.


Past Medical History:
Coronary artery disease DISEASE status post CABG [**2168**]
Diabetes DISEASE recently stopped glyburide and metformin per his doctor
[**First Name (Titles) **]
[**Last Name (Titles) 6093**] muscle weakness DISEASE NOS
spinal stenosis lumbar
MITRAL INSUF/AORT STENOS
PVD NOS
HL


Social History:
Social History: Lives by himself. Has a home care nurse [**First Name (Titles) **] [**Last Name (Titles) 6094**]s every 2 weeks. Uses a walker or cane and scooter when out
of apartment. No smoking no alcohol no rec drugs. has a Niece
[**Name (NI) **] [**Name (NI) **] who lives in [**Hospital1 1474**] [**Telephone/Fax (1) 6095**] (cell)
[**Telephone/Fax (1) 6096**] (work) is HCP according to patient.


Family History:
Family History: Father with MI in 50s. Brother with MI in 50s.
No history of cancer DISEASE


Physical Exam:
Vitals: 97.7/ 81/112/69/13 100% NRB
General: Alert oriented x3 no acute distress NRB in place
HEENT: Sclera anicteric MMM oropharynx clear EOMI PERRL
Neck: supple JVP not elevated no LAD
CV: Regular rate and rhythm normal S1 Admission Date: [**2154-3-24**] Discharge Date: [**2154-3-28**]

Date of Birth: [**2084-12-30**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of Breath Major Surgical DISEASE or Invasive Procedure:
None

History of Present Illness:
69 yo M h/o HIV COPD DISEASE presenting with shortness of breath DISEASE and
Admission Date: [**2108-3-8**] Discharge Date: [**2108-3-16**]

Date of Birth: [**2047-10-22**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
CP and fatigue DISEASE

Major Surgical or Invasive Procedure:
s/p CABGx3(LIMA-Admission Date: [**2114-7-13**] Discharge Date: [**2114-7-20**]

Date of Birth: [**2034-8-12**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Pt transferred from OSH for treatment of odontoid fracture DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mr. [**Known lastname 6105**] is a 79yo male with PMH significant for CHF DISEASE atrial
fibrillation DISEASE and CRI who presents from OSH with odontoid
fracture DISEASE s/p mechanical fall. Per patient he fell on Thursday
after he tried to get up from his bed. He admits to hitting his
head on the floor. He was brought to [**Hospital **] [**Hospital 1459**] Hospital
and was found to have an odontoid fracture DISEASE . He was transferred
to [**Hospital1 18**] for further work-up.
.
In the [**Hospital1 18**] ED his initial vitals were T 96.2 BP 81/60 AR 106
RR 16 O2 sat 92% RA DISEASE . He received Levaquiin 750mg IV x1 and was
started on Levophed which was turned off upon transfer to the
floor. He had repeat imaging which confirmed the fracture DISEASE . He
denies any fevers chills chest pain DISEASE SOB dizziness DISEASE abdominal
pain DISEASE or bloody/black tarry stools. He does admit to a
productive cough DISEASE over the past 3-4 weeks.
.
Of note patient was recently admitted to [**Hospital **] [**Hospital 1459**]
Hospital from [**Date range (1) 6106**] after he oresented with history of
recurrent dizziness DISEASE and his blood pressure was found to be in
the low 70's. He underwent several studies including a Holtor
monitor echo and PFTs. He was suggested to be discharged to
rehab but the patient refused.


Past Medical History:
1)Hypertension
2)Atrial fibrillation DISEASE s/p ICD placement Admission Date: [**2193-3-27**] Discharge Date: [**2193-4-3**]

Date of Birth: [**2154-3-3**] Sex: M

Service:

ADMISSION DIAGNOSIS: Klebsiella bacteremia/pneumonia.

HISTORY OF PRESENT ILLNESS: This is a 39-year-old gentleman
with acquired immunodeficiency syndrome DISEASE with fevers rigors DISEASE
and chills DISEASE times three days. Status post foscarnet infusion
via Port-A-Cath. Abdominal pain DISEASE last prior to discharge in
[**Hospital6 733**]. Blood cultures times two and
Mycobacterium avium-intracellulare cultures were drawn.

In the Emergency Department hypoxic at 87%. Temperatures had
ranged between 99 to 103.8. Cough DISEASE at baseline secondary to
chronic sinusitisAdmission Date: [**2193-12-19**] Discharge Date: [**2193-12-24**]

Date of Birth: [**2154-3-3**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Sulfamethoxazole/Trimethoprim / Lisinopril

Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
fever DISEASE to 103 degress chills fatigue vomiting DISEASE x 1 day

Major Surgical or Invasive Procedure:
none


History of Present Illness:
HPI: 39 year old man with AIDS DISEASE CD4 of 4 in [**4-29**] VL not done
who presented to the ED with 1 day of fevers DISEASE to 103 degrees at
home rigors DISEASE and chills DISEASE . On day of admission he also had 1
episode of nausea DISEASE vomited up food (non-bilious/ non-bloody)
that has resolved. Pt. notes chronic cough DISEASE he associated with
his thrush. Also had episode of diarrhea DISEASE 5 days ago that
resolved. Otherwise the patient denies headache DISEASE visual
changes neck pain/stiffness confusion chest pain DISEASE SOB
pleuritic CP abdominal pain (has chronic tenderness DISEASE
epigastrically) urinary changes new rash DISEASE or joint pain DISEASE .
.
On arrival to the ED he was found to have a temperature of 102.9
degrees HR in 130s SBP 106/61. Also was found to have a
lactate of 7.7 bicarb of 15 (normally in 20s) ARF DISEASE with cr of
2.5 (baseline 1.1-1.4). He was put on the MUST protocol and a
left subclavian line was placed. His initial CVP was 4. Mixed
venous sat was 85%. Blood cultures were drawn which grew [**2-28**]
bottles gram negative rods. He received doses of vanc/levo. His
BP dropped to 70/30 and he received 5 L of NS levophed started
after 3 L and SBP 85. A-line placed - ABG - 7.40/26/137 and the
lactate improved to 1.5. He started making urine with up to 60
cc per hour. He was admitted to the MICU.

He was continued on the sepsis DISEASE protocol in the MICU and
transfused with 2 units of blood for a HCT of 18. He was weaned
from levophedrine around 4 am and has since had a stable BP in
the 110's.

Patient was then transferred to floor on [**12-20**] at that time he
reported feeling much improved but not quite at his baseline.
He denies continued fevers DISEASE or chills abdominal pain diarrhea DISEASE
nausea vomiting DISEASE or other concerns. He says he is currently
almost blind from the CMV retinitis DISEASE and [**Doctor Last Name **] detect some light
in his left eye.

Past Medical History:
1. HIV since '[**77**] now with AIDS DISEASE CD4 of 4 complicated by
Klebsiella oxytoca pna with pos. BCX (pan-[**Last Name (un) 36**]) [**Last Name (un) 6108**]
bacteremia DISEASE in [**6-28**] cytomegalovirus retinitis DISEASE currently [**Doctor Last Name **]
oroesophageal candidiasis DISEASE oral hairy leukoplasia toxo in [**2184**]
anal warts lipodystrophy DISEASE .
2. Dermatitis DISEASE .
3. Hypertension DISEASE .
4. Hemorrhoids.
5. Anemia DISEASE .
6. Leukopenia DISEASE .
7. Angioedema DISEASE .
8. Ulcerations.
9. Herpes simplex DISEASE .
10. Shingles.
11. Hepatitis B. DISEASE
12. Bacterial meningitis DISEASE .
13. EF of 45%
14. peripheral neuropathy DISEASE


Social History:
Lives in JP with his male partner. Denies current alcohol use.
Smoked 1 ppd for 15 years quit in [**2179**]. Used to use marjuana
now on marinol. No IVDA.

Family History:
father had MI at age 41
mother had salivary cancer DISEASE in her 60's

Physical Exam:
V: Tm 102.9 Tc 97.7 P 85 BP 109/69 R20 99% RA DISEASE
Gen: cachectic DISEASE blind pleasant man in no apparent distress
Skin: molluscum contagiosum DISEASE over face. Port-o-cath R chest
nontender no erethema
HEENT: pupils 3mm and equal but not reactive to light. OP with
thrush over palate DISEASE and tongue
Resp: CTAP B
CV: RRR nl s1s2 II/VI SEM at RUSB
Abd: soft NTND Admission Date: [**2194-2-1**] Discharge Date: [**2194-2-7**]

Date of Birth: [**2154-3-3**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Sulfamethoxazole/Trimethoprim / Lisinopril

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
39y/o M with HIV/AIDS last CD4 count 4 blind [**1-29**] CMV
retinitis DISEASE hep B presents with fatigue DISEASE and fever DISEASE to 103 at home.

Major Surgical or Invasive Procedure:
1. removal of Portacath
2. placement of triple lumen central catheter


History of Present Illness:
Pt felt tired in the day prior to admission with decreased
appetite. Developed fever DISEASE to 103F. Denies nausea vomiting DISEASE
chills abdominal pain DISEASE or diarrhea DISEASE . Denies dysuria nasal
congestion chest congestion DISEASE . Denies headacheAdmission Date: [**2198-1-22**] Discharge Date: [**2198-2-4**]

Date of Birth: [**2137-3-19**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 6123**] was a 60-year-old
right handed African American male who was admitted on
[**2198-1-22**] with history of acute left weakness DISEASE . He had a past
medical history of diabetes coronary artery disease DISEASE and
prior stroke DISEASE . He presented to the Emergency Room with sudden
onset left sided weakness said by report occurring
approximately 30 minutes before presenting to the Emergency
Room. The patient was a patient of Dr. [**Last Name (STitle) 6124**] and the
patient stated at that moment he takes Coumadin for prior
strokes DISEASE .

The patient vomited and aspirated coming back from CT scan
and drove his O2 saturation transiently to the 60s requiring
intubation for airway protection.

PAST MEDICAL HISTORY:
1. CVA DISEASE in [**2193**] with right sided dysmetria left parietal
stroke DISEASE in [**2192**] with left supraclinoid IC stenosis.
2. Diabetes DISEASE .
3. Hypertension DISEASE .
4. Coronary artery disease DISEASE .

MEDICATIONS ON PRESENTATION: He said that he took Coumadin
and he could not remember the rest of his medications.

PHYSICAL EXAMINATION IN THE EMERGENCY ROOM: He presented
with a blood pressure of 190/118 temperature of 96.8 and
saturation of 97%. General: The patient appeared stated
age lying in bed looking to the right in no acute distress.
HEENT: Normocephalic atraumatic sclerae white. Neck:
Supple. Lungs: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm normal S1 S2 no
murmurs gallops or rubs. Abdomen: Normal bowel sounds
soft nontender nondistended. Extremities: Warm no
clubbing cyanosis DISEASE or edema DISEASE . Neurologic examination in the
Emergency Room: Cognitive: He was awake alert but not
fully cooperative. Able to state his name but he was not
able to distinct that there was any problem with him at that
point. He was able to name objects follow simple commands
with possible perseveration. Speech: Normal voice quality
articulation comprehension. Fluent without paraphasias.
Cranial nerves: Face with left lower droop. Extraocular
movements gaze deviation to the right but was able to look
to the midline and past midline to the left. Gaze appears
conjugate. Visual fields possibly decreased but treads on
the left. Pupils are reactive to light directly and
consensually and accommodation. Palate was symmetric and
tongue was midline. Hearing is grossly intact. Sensation
difficult to assess. Motor examination: He was able to show
his left thumb and squeeze left hand on command. He was not
able to lift left arm against gravity. He was able to raise
his left leg against gravity but was not able to move his
left foot on command. He was able to raise right arm leg
and moves foot without difficulty. Reflexes were Admission Date: [**2118-10-6**] Discharge Date: [**2118-10-9**]


Service: MEDICINE

Allergies DISEASE :
Morphine

Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Dyspnea cough DISEASE

Major Surgical or Invasive Procedure:
ICU monitoring TTE CT scan chest transfused 1U PRBCs


History of Present Illness:
The patient is an 87 year old female with history of coronary
artery disease DISEASE and congestive heart failure DISEASE (EF 34% in [**2114**]) who
presents with cough DISEASE of 2 week duration productive of white
sputum and increasing shortness of breath DISEASE at rest as well as
dyspnea DISEASE on exertion. She also reports some orthopnea DISEASE --she has
slept upright for years. No recent CP abd pain DISEASE fevers N/V/D
black or bloody stools. Taking good POs. Intermittent leg
swelling DISEASE none today.
.
In ED initial VS: T98.3 HR 110 BP 116/68 RR 33 SaO2 98% on
2 L NC. CXR showed mild to moderate CHF DISEASE . Levaquin 750 given.
Initial CK flat trop 0.02. BNP 15000. Lactate 3. EKG changed
from prior.

Past Medical History:
1. CAD s/pMI [**2110-3-4**] cath showed right coronary artery that
was dominant with 100% mid occlusion which was stented LAD had a
50-70% stenosis mid portion Obtuse marginal 1 was totally
occluded
2. total abdominal hysterectomy
3. SBO with resection
4. Right CEA [**2110**]
5. DVT DISEASE on coumadin
6. Pelvic fracture DISEASE s/p fall
7. B12 deficiency anemia DISEASE


Social History:
Lives with son. She walks with a cane. She denies current
tobacco but with a 50 pack year history.


Family History:
Non-contributory. No osteoporosis DISEASE .


Physical Exam:
VS (on arrival to MICU): T 99.4 HR 120 --Admission Date: [**2101-6-30**] Discharge Date: [**2101-7-7**]

Date of Birth: [**2023-9-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypoglycemia hypotension DISEASE

Major Surgical or Invasive Procedure:
Central venous catheter placement.


History of Present Illness:
Ms. [**Known lastname 6129**] is a 77yo female with PMH significant for COPD DISEASE on 4L
NC HTN anemia DISEASE and recent pubic ramus fracture DISEASE who is being
transferred to the MICU for hypotension hypoxemia DISEASE and
hypoglycemia DISEASE . Per her family she fractured her pubic ramus 3
weeks ago. She was evaluated at the [**Hospital1 756**] and was found to be
a non-surgical candidate. She was then transferred to [**Hospital 882**]
Hospital and admitted. During her stay she was found to have a
UTI DISEASE and was treated with Cipro. Her daughter states that after 5
days of treatment she found out that the bug in her urine was
resistent to the Cipro. She was then apparently treated with
Cefpodoxime and the last day was [**6-19**]. She had a foley in place
during these times which was removed yesterday. Two days after
being at the NH she represented to [**Hospital1 882**] ED with symptoms
suggestive of a bowel obstruction DISEASE . Of note she has been on
narcotics during this time. She was then discharged back to
Bostonian where she has been since [**6-18**]. Per daughter she has
had poor intake over the past few days.
At 8:15am this morning her BS was low according to the
glucometer. She was immediately given Glucagon IM and glucose
gel. Her BS increased to 40 at 8:50am after a second glucagon
shot. Blood sugar remained at 42 per nurse [**First Name (Titles) **] [**Last Name (Titles) **]. EMS was called
and she was immediately brought to [**Hospital1 18**].
In the ED initial vitals were T 98.2 BP 119/70 AR 78 RR 28 O2 sat 80% RA DISEASE . She was immediately placed on NRB DISEASE and her O2 saturation increased to 92%. Repeat blood sugar was 135. She
received ASA 325mg Levaquin 750mg IV Flagyl 500mg IV Zofran
4mg IV and 3L normal saline. She was then transferred to the
MICU for further management.

Past Medical History:
1)Pubic ramus fracture DISEASE
2)Syncope
3)COPD on 4L at home
4)IDDM
5)Hypertension
6)Anemia DISEASE (followed by hematologist)

Social History:
Patient lives with husband. [**Name (NI) **] current tobacco alcohol or
IVDA.

Family History:
NC

Physical Exam:
vitals T 95.6 BP 161/84 AR 89 RR 20 O2 sat 86% on 6L NC
Gen: Awake responsive to commands increased respiratory effort
HEENT: Mucous membranes slightly dry
Heart: RRR no audible mrg
Lungs: CTAB Admission Date: [**2101-7-8**] Discharge Date: [**2101-7-29**]

Date of Birth: [**2023-9-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension DISEASE

Major Surgical or Invasive Procedure:
Endotracheal intubation x 2
Central venous line
PICC line
Pleurocentesis
Arterial line
DC cardioversion

History of Present Illness:
Ms. [**Known lastname 6129**] is a 77yo female with PMH significant for COPD DISEASE on 4L
NC HTN anemia DISEASE and recent pubic ramus fracture DISEASE who was
recently in the MICU for hypoxia hypotension DISEASE and thought to
have urosepsis DISEASE . At that time she was stared on broad spectrum
antibiotics (Vancomycin/Cefepime) and narrowed to cefpodoxime on
discharge to complete a 7-day course. She was discharged to
rehab on [**2101-7-7**]. At rehab on [**2101-7-8**] she was found by
family members to be lethargic somnolent and tachypneic DISEASE . She
was transferred to [**Hospital1 18**] for further evaluation.
In the ED initial vitals were T:97.9 BP:70/38 HR:73 RR:16
O2Sat:97% on RA DISEASE . For the hypotension DISEASE she was given 5 litres
resuscitative crystalloid and a left IJ central line was placed
after unsuccessful attempt at right IJ. Patient was also found
to have abdominal tenderness DISEASE and an abdominal CT scan was
ordered and per our wet read showed dilated colon DISEASE with stool
throughout. She was given Vancomycin and
Piperacillin-Tazobactam x 1 dose after blood and urine cultures
were sent. She was then transferred to MICU.

Past Medical History:
1)Pubic ramus fracture DISEASE
2)Syncope
3)COPD on 4L at home
4)IDDM
5)Hypertension
6)Anemia DISEASE (followed by hematologist)

Social History:
Patient lives with husband [**Name (NI) 6132**] recently discharged to a rehab
one day prior. No current tobacco alcohol or IVDA.


Family History:
NC

Physical Exam:
vitals T 97.1 BP 103/46 HR 70 RR 19 O2 sat 94% on 4 L NC
Gen: Awake responsive to commands breathing comfortably
HEENT: Mucous membranes dry
Heart: RRR no audible mrg
Lungs: CTAB diminished breath sounds bilaterally
Abdomen: Soft distended tympanic sounds throughout with
percussion tender to palpation diffusely no rebound or
guarding
Extremities: 1Admission Date: [**2188-8-5**] Discharge Date: [**2188-8-18**]

Date of Birth: [**2122-1-10**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Atenolol

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
bright red blood per rectum

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
66 yo M with mechanical AVR on [**First Name3 (LF) **] with aortic valve
enterococcal endocarditis DISEASE and ring abscess and recent GIB DISEASE
([**2188-8-4**]) after colonic polypectomy s/p 7 units pRBC and INR
reversal who was transferred to [**Hospital1 18**] MICU for management of
hypotension DISEASE and AVR abscess.
.
On arrival in the MICU his hypotension DISEASE had been resolved. His
Hct remained stable and he was placed on heparin drip for
anticoagulation. His EKG showed PR prolongation to 400 msec.
Repeat TEE showed heterogeneous thickening of the peri-aortic
tissue consistent with an aortic root abscess. EP
cardiothorasic surgery and ID were consulted. EP and CSURG felt
that this could be conservatively managed until surgery and
recommends rehab with regular EKG. ID recommended amp Admission Date: [**2154-4-9**] Discharge Date: [**2154-4-18**]

Date of Birth: [**2084-12-30**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Respiratory distress DISEASE

Major Surgical or Invasive Procedure:
BiPap
Intubation extubation ([**2154-4-13**])


History of Present Illness:
69 year old male with history of HIV (CD4 116 [**2154-4-8**]) COPD DISEASE
(2-4L at home) DVT DISEASE on coumadin hypertension chronic lower
back [**Last Name (un) 2187**] osteoporosis DISEASE who presents with respiratory distress DISEASE .
The patient had been recently admitted 5/13-16/[**2153**] for COPD DISEASE
exacerbation and treated with nebs azithromycin prednisone
(slow taper). The patient presented to the ED on [**2154-4-2**] for
dyspnea DISEASE but left AMA before admission. He was sent to the ED on
[**2154-4-8**] but left AMA again with prednisone and azithromycin
prescriptions which he never filled. He had seen Dr. [**Last Name (STitle) **] in
pulmonary clinic yesterday and had been non-compliant with
prednisone taper. He endorsed Admission Date: [**2188-10-6**] Discharge Date: [**2188-10-11**]

Date of Birth: [**2122-1-10**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Atenolol / Lisinopril

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Endocarditis DISEASE

Major Surgical or Invasive Procedure:
[**2188-10-7**] - Redo sternotomy Aortic valve replacement(21mm St.
[**Male First Name (un) 923**] Regent Mechanical)/Closure of aortic abscess DISEASE (Patch
pericardium)/Ascending Aorta Replacement(28mm Gelweave graft).


History of Present Illness:
66M w h/o bicuspid aortic valve s/p DISEASE mechanical AVR (on
[**Male First Name (un) **])
in [**2171**] at [**Hospital1 18**]. The ascending aorta was noted to be 4.5cm at
the time and was not replaced. He had an episode of
enterococcal aortic valve endocarditis DISEASE in [**2187-11-13**].
Enterococcal endocarditis DISEASE was again diagnosed in [**2188-7-13**]
with
concern for aortic valve ring abscess on echo. The patient
was evaluated for the source of his enterococcal bacteremia DISEASE and
mild ischemic colitis DISEASE and several polyps were found. A
polypectomy was performed. An EGD found mild gastritis DISEASE and he
was
started on Pantprazole. The patient was discharged on ampicillin
and gentamicin on [**2188-7-24**].
He was admitted on [**2188-9-9**] for preoperative workup and cardiac
cath. Cardiac cath did not reveal obstructive coronary lesiosn.

On admission the patient exhibited gait instability and
neurology was consulted. It was determined that the patient was
experiencing vestibulopathy DISEASE secondary to gentamycin. MRI
revealed very small microembolic infarcts DISEASE which were attributed
to his time off [**Date Range **] resulting in subtherapeutic INR or
less likely septic DISEASE emboli. Gentamicin was discontinued and the
patient was discharged home on ampicillin which will continue
until surgery. ID has continued to follow him as an outpatient
with weekly blood cultures. The patient returns for heparin
bridge preoperatively.


Past Medical History:
-Mechanical AVR [**3-/2172**]
-Enterococcal faecalis endocarditis DISEASE diagnosed in [**11-20**] AVR ring
abscess diagnosed [**7-22**]
-Hypertension
-Hyperlipidemia
-Ischemic colitis DISEASE
-Colonic polyps
-GERD
-Hiatal hernia DISEASE
-Gastritis
-Diverticulosis

Social History:
Lives with wife in [**Name (NI) 6134**] MA. Former smoker. Rare ETOH.


Family History:
Non-contributory.

Physical Exam:
Pulse:80 Resp:16 O2 sat:99%
B/P Right:122/60 Left:122/64
Height: 5'[**87**]Admission Date: [**2190-2-8**] Discharge Date: [**2190-2-15**]

Date of Birth: [**2144-2-23**] Sex: M

Service: ENT SURGERY

CHIEF COMPLAINT: Chronic aspiration.

HISTORY OF THE PRESENT ILLNESS: This is a 45-year-old male
with Down's syndrome DISEASE with frequent aspirations resulting in
several episodes of aspiration pneumonia DISEASE . The patient has
had a gastric feeding tube since [**2182-1-3**]. A
swallowing video fluoroscopy in [**2180**] revealed moderate to
severe oropharyngeal swallowing disturbance DISEASE with aspiration
after the swallow and poor laryngeal sensitivity noted by
absent cough DISEASE following the aspiration.

PAST MEDICAL HISTORY:
1. Down's syndrome DISEASE with profound mental retardation.
2. Hepatitis B DISEASE carrier.
3. Osteoporosis.
4. Hiatal hernia DISEASE .
5. Allergic rhinitis DISEASE .
6. Constipation.
7. Left retractile testis DISEASE .
8. Right hip subluxation DISEASE .
9. Atopic dermatitis DISEASE .

PAST SURGICAL HISTORY:
1. Right total hip replacement in [**2188-6-2**].
2. G tube placement in [**2182-1-3**].
3. Excision of thigh lipoma DISEASE in [**2182-5-4**].
4. Left cataract DISEASE extraction with lens implant.

ALLERGIES: Keflex which causes a rash DISEASE Reglan which causes
dystonia DISEASE and acetazolamide.

ADMISSION MEDICATIONS:
1. Protonix 40 b.i.d.
2. Theophylline 200 q.p.m.
3. Multivitamin.
4. Milk of magnesia.
5. Loratadine 10 mg every evening.
6. Lactobacillus 40 b.i.d.

SOCIAL HISTORY: The patient is a resident of [**Location 6151**]
Developmental Center.

PHYSICAL EXAMINATION ON ADMISSION: Cardiac: Regular rate
and rhythm. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft nondistended nontender with a G tube in
place. Extremities: Severe muscular atrophy DISEASE no edema DISEASE
clubbing DISEASE or cyanosis DISEASE .

HOSPITAL COURSE: The patient was admitted to preop and
holding where he underwent narrow-field laryngectomy. The
patient tolerated this procedure well. Please see the
operative note for details. Chest x-ray postoperatively
revealed a tracheostomy tube in good position with no
pneumothorax DISEASE . The patient was transferred to the Surgical
Intensive Care Unit on the ventilator. He was placed on IV
Clindamycin and IV Flagyl.

On postoperative day number one it was attempted to wean the
patient off the ventilator. The patient was weaned to CPAPAdmission Date: [**2127-7-10**] Discharge Date: [**2127-7-15**]


Service: UROLOGY

Allergies DISEASE :
Tylenol / Advil

Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
kidney stone DISEASE

Major Surgical or Invasive Procedure:
cystoscopy with retrograde placement of a ureteral stent


History of Present Illness:
HPI: This is a [**Age over 90 **]M with h/o of prostate hyperplasia DISEASE s/p TURP x2
presents from home c/o diffuse abd pain DISEASE that radiated to the
RLQ. A CTU revealed and 4mm obstructing R ureteral stone Admission Date: [**2154-7-2**] Discharge Date: [**2154-7-10**]

Date of Birth: [**2096-7-25**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Vicodin / Lisinopril

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pain DISEASE

Major Surgical or Invasive Procedure:
s/p Aortic Valve Replacement ([**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] Regent Mechanical)
[**2154-7-2**]


History of Present Illness:
57 year old female with history of aortic stenosis DISEASE followed by
serial echocardiogram and now symptomatic with increased
exertional chest burning DISEASE

Past Medical History:
Aortic Stenosis DISEASE
Hypertension DISEASE
Elevated cholesterol
Palpitations
Gastric Esophageal reflux disease DISEASE
Duodenal ulcer DISEASE
Depression DISEASE
Attention deficit disorder DISEASE
H pylori


Social History:
Semi retired architect/professor
Married lives with spouse
[**Name (NI) 1139**] - 20 pack year history quit 2 years ago
Etoh denies


Family History:
Father with PVD DISEASE deceased MI age 57

Physical Exam:
General HR 52 RR 16 146/61
Skin and HEENT: unremarkable
Neck supple full ROM
Chest CTA bilat
Heart RRR
Abd soft ND NT Admission Date: [**2115-7-27**] Discharge Date: [**2115-7-29**]


Service: SURGERY

Allergies DISEASE :
Penicillins / Sulfa (Sulfonamides) / Morphine

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p mechanical fall with medial orbital wall fx and increased L
eye intraocular pressures (46-48) as well as hemorrhagic DISEASE
chemosis DISEASE L eye L lat canthus lac lacs of R elbow and L knee

Major Surgical or Invasive Procedure:
none


History of Present Illness:
88 year-old woman fell while using walkerAdmission Date: [**2162-3-19**] Discharge Date: [**2162-3-20**]

Date of Birth: [**2085-8-29**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
bright red blood per rectum

Major Surgical or Invasive Procedure:
sigmoidoscopy

History of Present Illness:
76-year-old man with history of diverticulosis prostate cancer DISEASE
stroke DISEASE on Aggrenox DM2 hypertension DISEASE presented with BRBPR.
Patient reported having 2 episodes of bleeding DISEASE with bowel
movements the night of presentation claiming that toilet bowl
was filled with bright red blood. Denies abdominal pain DISEASE
lightheadedness chest pain shortness of breath DISEASE .

Patient had a colonoscopy many years ago--he doesn't remember
when-- which was reportedly Admission Date: [**2119-10-31**] Discharge Date: [**2119-11-5**]

Date of Birth: [**2072-1-20**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Lisinopril

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mr. [**Known lastname **] is a 47 year old male with HIV( last CD4 301 [**8-7**] DISEASE )
ESRD DISEASE on PD dilated cardiomyopathy DISEASE (EF 30%) who presents with
cough DISEASE and SOB. Patient notes being in his usual state of health
until Admission Date: [**2104-2-20**] Discharge Date: [**2105-3-3**]

Date of Birth: [**2027-9-18**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 6193**] is a 77 year old
Russian-speaking man with known coronary artery disease DISEASE with
a one year history of worsening chest pain DISEASE now with unstable
angina scheduled for cardiac catheterization in [**2104-10-25**] after a positive stress test. The patient elected to
postpone the procedure at that time. The patient presented
to the Emergency Room on [**2-19**] with a complaint DISEASE of chest pain DISEASE
and shortness of breath DISEASE .

PAST MEDICAL HISTORY: Significant for diabetes mellitus DISEASE type
IIAdmission Date: [**2115-1-21**] Discharge Date: [**2115-1-23**]


Service: MEDICAL ICU/[**Hospital1 212**]

HISTORY OF PRESENT ILLNESS: The patient is an 83 year-old
white male with a history of large left sided lung mass who
recently had a biopsy who presented with mental status
changes and vomiting DISEASE followed by hypoxemia DISEASE . He had a biopsy
of his lung mass on [**2115-1-18**]. On the day prior to
admission the patient complained of pain DISEASE at his biopsy site
which is controlled with Percocet. On the morning of
admission he developed a fever DISEASE to 101.7 degrees Fahrenheit
rectally. His O2 sats were 90% on 2.5 liters nasal cannula.
A chest x-ray revealed left upper lobe and right lower lobe
infiltrates and the patient was started on Levofloxacin for
presumed pneumonia DISEASE . Later that day he gradually became more
lethargic and required more pain DISEASE medication. After the one
episode of vomiting DISEASE the patient's O2 sats fell to the 80s on
2.5 liters per minute nasal cannula and he was 92% on 8
liters of nasal cannula. He was then transferred to the [**Hospital1 1444**] for further management. On
arrival the patient required 100% nonrebreather face mask to
keep his O2 sats in the high to mid 90s. A chest x-ray
revealed left lower lobe collapse and consolidation with an
additional infiltrate around the mass and a moderate sized
left pleural effusion DISEASE . He was given a dose of Levofloxacin
and Flagyl in the Emergency Department. Arterial blood gas
on a nonrebreather mask revealed pH at 7.2 on oxygen CO2 of
80 and oxygen of 125. A trial of BIPAP was attempted
however the patient could not tolerate the mask. He was
then placed back on a nonrebreather with almost identical
arterial blood gas of 7.20 79 and 125. The MICU team was
then called to evaluate the patient.

PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease DISEASE on 2 liters nasal
cannula at home. Pulmonary function tests in [**2107**] showed an
FEV of 0.62 FVC of 1.3 and FEV/FVC of 45%.
2. Peripheral vascular disease DISEASE status post right femoral
popliteal bypass graft.
3. Coronary artery disease DISEASE status post percutaneous
transluminal coronary angioplasty and myocardial infarction DISEASE .
4. Hypertension.
5. Type 2 diabetes.
6. Benign prostatic hypertrophy DISEASE status post transurethral
resection of the prostate.
7. Depression.
8. Essential tremor DISEASE .
9. Bladder cancer DISEASE .
10. Benign positional vertigo DISEASE .
11. Lung cancer metastatic to the liver. Recent biopsy
performed with biopsy results pending.

ALLERGIES: Sulfa rash DISEASE .

MEDICATIONS ON ADMISSION: Heparin Tylenol #3 aspirin
Lactulose Fluoxetine Isosorbide mononitrate Imdur
Lisinopril Fluticasone Atrovent Albuterol Senna and
Colace.

HOSPITAL COURSE: The [**Hospital 228**] hospital course was
complicated by his continued respiratory distress DISEASE . The
patient continued to request no invasive measures including
no intubation no resuscitation and no chest tube placement.
Essentially the patient wanted to die peacefully and not have
any invasive measures done to sustain his life. At that
point the patient was transferred to the MICU to the medical
floor. He continued to have respiratory decline and was
eventually unresponsive and made comfort measures only by his
family whose daughter [**Name (NI) 4051**] [**Name (NI) 6203**] who is his health care
proxy. The patient passed on [**2115-1-23**] at around
5:00 p.m. He died of respiratory failure DISEASE secondary to lung
cancer DISEASE secondary to pneumonia DISEASE . The patient's family declined
a post mortem examination.






[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 4263**]

Dictated By:[**Doctor Last Name 6204**]

MEDQUIST36

D: [**2115-1-24**] 10:01
T: [**2115-1-24**] 10:23
JOB#: [**Job Number 6205**]
Admission Date: [**2112-4-11**] Discharge Date: [**2112-4-25**]

Date of Birth: [**2041-7-25**] Sex: F

Service: GREEN [**Last Name (un) **]

HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
female who presented with a five day history of nausea DISEASE and
vomiting DISEASE associated with abdominal pain DISEASE . The patient was
unable to tolerate a liquid diet and complained of
constipation DISEASE on admission. The patient last had a
colonoscopy in [**2110-12-17**] which demonstrated adenomatous DISEASE
polyps in the mid-descending colon. The patient had one
similar episode of nausea DISEASE and vomiting DISEASE with abdominal pain DISEASE
that was peristaltic in nature one year prior to presentation
which resolved after an enema in the emergency room. The
patient otherwise denied chest pain dysuria melena DISEASE
hematochezia DISEASE or any other symptoms. She did complain of
occasional shortness of breath DISEASE .

PAST MEDICAL HISTORY: Coronary artery disease DISEASE MI.
Peripheral vascular disease DISEASE . Atrial fibrillation DISEASE .
Osteoporosis DISEASE . Hyperlipidemia. Breast cancer DISEASE . Asthma.
Hypothyroidism DISEASE . History of UTIs DISEASE . Adenocarcinoma of the
rectum. Congestive heart failure DISEASE with ejection fraction of
50 percent.

PAST SURGICAL HISTORY: Left mastectomy. Low anterior
resection in [**2108**]. Open reduction and internal fixation of
the right tibia. Aortic-femoral bypass. Bilateral THR.
Left femoral endarterectomy Dacron angioplasty.

MEDICATIONS ON ADMISSION: Amiodarone 200 mg p.o. q.d. Imdur
10 mg p.o. t.i.d. Advair one to two puffs q.12 hours p.r.n.
albuterol one to two puffs q.six hours p.r.n. alendronate 5
mg p.o. q.day nitrofurantoin aspirin 325 mg p.o. q.day
Lopressor 25 mg p.o. q.day folic acid 1 mg p.o. q.day
vitamin B-12 100 mcg p.o. q.day multivitamin one tablet p.o.
q.day.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: The patient had a history of a 40 pack year
smoking history and quit five years ago.

PHYSICAL EXAMINATION: On admission temperature 99.0 pulse
81 blood pressure 137/76 respiratory rate 16 oxygen
saturation 97 percent in room air. In general the patient
was a well-developed well-nourished Caucasian female in no
acute distress. HEENT pupils equal round reactive to
light anicteric extraocular muscles intact. Neck supple
midline no lymphadenopathy DISEASE or tenderness DISEASE . Chest lungs were
clear to auscultation bilaterally. Cardiovascular regular
rate and rhythm positive S1 S2 no murmurs rubs or
gallops. Abdomen soft tender in the left lower quadrant
mostly but evidence of diffuse tenderness. No masses no
organomegaly DISEASE . Rectal positive stool guaiac positive no
masses. Extremities warm and well perfused no edema DISEASE
nontender.

LABORATORY DATA: On admission white blood cell count 4.4 32
bands hematocrit 42.7 platelets 273. INR 1.2 PT 13.2 PTT
25.9. ALT 17 AST 19 alkaline phosphatase 106 total
bilirubin 0.5. Sodium 131 potassium 4.1 chloride 91
bicarb 22 BUN 28 creatinine 0.9 glucose 140. Calcium 9.7
magnesium 1.7 phosphate 4.0. Lactate 1.0. KUB showed
dilated small bowel DISEASE with positive air fluid levels. CT
angiogram previously ordered by patient's pulmonologist showed
no evidence of pulmonary embolus DISEASE but an enlarged gallbladder.
EKG ST depressions in leads V5 to V6 biphasic T waves in V2
and V3 normal sinus rhythm at 84 beats per minute with normal
axis.

IMPRESSION: The patient is a 70 year old female with a
history of coronary artery disease atrial fibrillation DISEASE
breast cancer asthma hypothyroidism DISEASE and adenocarcinoma DISEASE of
the rectum who presents with nausea DISEASE and vomiting abdominal pain DISEASE and the presence of air fluid levels on KUB. The
admitting diagnosis was potential small bowel obstruction.

HOSPITAL COURSE:
1. FEN/GI. The patient was admitted to the surgery service
with the admitting diagnosis of possible small bowel obstruction DISEASE . She was made NPO and an NG tube was placed and
IV fluids were administered. Due to her clinical lack of
improvement the patient was taken to the operating room on
[**2112-4-12**] where she underwent exploratory laparotomy and lysis
of adhesions DISEASE for high grade small bowel obstruction DISEASE . The
surgery itself was uncomplicated and she had minimal blood
loss.

The patient's postoperative course was complicated by
hypotension DISEASE post-op as well as congestive heart failure DISEASE . The
patient required about 10 liters of intravenous resuscitation
immediately post-op. She subsequently developed congestive heart failure DISEASE and atrial fibrillation DISEASE which were treated with
IV furosemide and IV amiodarone for rate control and she
converted to normal sinus rhythm. She diuresed well with
furosemide but due to her persistent respiratory distress DISEASE
and increasing oxygen requirements she was transferred to
the MICU for further more careful monitoring.

The [**Hospital 228**] hospital course was also complicated by fever DISEASE
which reached a maximum temperature of 101.8 on [**4-12**]. Blood
cultures were obtained and are negative to date. She also
had anemia DISEASE with hematocrit of 27 for which she received one
unit of packed red blood cells.

The patient's aggressive diuresis continued. At one point
Lasix was held due to episodes of hypotension DISEASE . Again
hypotension DISEASE responded to fluids and Lasix was restarted
without incident. The patient's oxygen was weaned down from
a nonrebreather to 1 liter at the time of this dictation.
Her diet was advanced slowly and by the time of discharge she
was passing flatus had bowel movements DISEASE was not nauseous
was tolerating a regular diet.

The patient had an echocardiogram which showed an ejection
fraction of 55 to 60 percent. There was also focal right
ventricular hypokinesis DISEASE with trivial mitral regurgitation DISEASE .
Overall it was within normal limits.

The patient had repeat chest x-ray which showed interval
improvement in her congestive heart failure DISEASE .

The patient's electrolytes were repleted as necessary. Her
pain DISEASE was well controlled with oral pain DISEASE medications. She did
develop loose stools at one point but Clostridium difficile DISEASE
toxin was negative.

CONDITION ON DISCHARGE: Good.

DISCHARGE STATUS: Rehabilitation facility ([**Hospital 100**] Rehab
Facility).

DISCHARGE DIAGNOSES:
1. Small bowel obstruction.
2. Postoperative atrial fibrillation DISEASE .
3. Coronary artery disease DISEASE .
4. Hypercholesterolemia DISEASE .
5. Congestive heart failure DISEASE .
6. Asthma.

DISCHARGE MEDICATIONS:
1. Albuterol one to two puffs q.four to six hours p.r.n.
2. Fluticasone propionate two puffs b.i.d. p.r.n.
3. Advair 50 mcg one puff q.12 hours p.r.n.
4. Metoprolol 12.5 mg p.o. b.i.d.
5. Amiodarone 200 mg p.o. q.d.
6. Bisacodyl 10 mg suppository p.r.n.
7. Protonix 40 mg p.o. q.d.
8. Colace 100 mg p.o. t.i.d.
9. Ibuprofen 400 mg p.o. q.six hours.
10. Furosemide 20 mg p.o. b.i.d.
11. Zofran 4 mg q.four to six hours p.r.n. nausea DISEASE .

FOLLOWUP: The patient was instructed to follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in two weeks.






[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**] M.D. [**MD Number(1) 4954**]

Dictated By:[**Name8 (MD) 6206**]
MEDQUIST36

D: [**2112-4-25**] 08:29
T: [**2112-4-25**] 09:13
JOB#: [**Job Number 6207**]

cc:[**Hospital6 6208**]Admission Date: [**2148-2-3**] Discharge Date: [**2148-2-7**]

Date of Birth: [**2087-6-7**] Sex: F

Service: SURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Pedestrian struck by motor vehicle

Major Surgical or Invasive Procedure:
[**2147-2-3**]: Chest tube insertion


History of Present Illness:
60 year old female pedestrian struck at Admission Date: [**2112-9-8**] Discharge Date: [**2112-9-14**]

Date of Birth: [**2041-7-25**] Sex: F

Service: MED

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 6209**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
71 yo female extensive PMHx admitted with hypotension DISEASE and
hypoxia DISEASE most likely due to RML/RLL pneumonia DISEASE . Pt in usual state
of health until night before admissin when experienced flare of
asthma DISEASE and no improvement on albuterol continued mild SOB
chest tightness DISEASE but no cough DISEASE . Pt also experienced subjective
fevers DISEASE and chills DISEASE . Remainder of ROS neg. In the ED SBP 70s
transiently on dopamine and then levophedAdmission Date: [**2114-10-26**] Discharge Date: [**2114-10-30**]

Date of Birth: [**2041-7-25**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Metrogel / Desipramine

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Ms. [**Known lastname 6164**] is a 73-year-old woman
who had fallen several days ago and who developed shortness DISEASE
of breath. She was found to have a large hemothorax DISEASE on chest
CT.


Major Surgical or Invasive Procedure:
right vats evacuation of hematoma DISEASE


History of Present Illness:
73 y/o woman tripped [**2114-10-23**] and fell onto R. head R. eye R.
side and R. knee presents with R hemothorax DISEASE .

Past Medical History:
CAD s/p MI in 94
PVD DISEASE (s/p aorto-fem bypass and L femoral endarterectomy)
L Breast CA s/p mastectomy
presumbed diastolic disfunction DISEASE
colon adenocarcinoma ' DISEASE [**08**] s/p LAR with Chemo and XRT
SBO s/p XLap with LOA in [**3-20**]
asthma DISEASE
hypothyroidism DISEASE
hyperlipidemia DISEASE
osteoporosis DISEASE
ORIF R tibia
bilateral THR [**2110**]
recurrent UTI DISEASE


Social History:
no tobacco alcohol IVDA
lives with husband


Family History:
NC

Physical Exam:
general: 73 yo female w/ SOB after trip and fall.
HEENT: ecchymosis DISEASE over right face and orbit.
chest: breath sounds decreased at right base. left clear. Admission Date: [**2117-2-6**] Discharge Date: [**2117-2-10**]

Date of Birth: [**2041-7-25**] Sex: F

Service: SURGERY

Allergies DISEASE :
Metrogel / Desipramine / Sanctura

Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
sepsis DISEASE

Major Surgical or Invasive Procedure:
R IJ central venous line placement

History of Present Illness:
The patient is a 75-year-old female who complains of
progressively worsening rectal and buttock pain DISEASE over the past 2
weeks. Upon presenting to the [**Hospital1 18**] ED today she initially had
a
HR of 77 with a BP of 105/69 but quickly became hypotensive DISEASE to
56/40 with a heart rate of 98. Sepsis DISEASE protocol was initiated. A
central line was placed with great difficulty due to
near-complete IVC collapse. She was placed on a norepinephrine
drip and underwent a CT scan when she was somewhat stable. The
scan shows a large pre-sarcal abscess with rim enhancement and
air and fat stranding tracking to a R hip prosthesis.

On [**2116-12-20**] she underwent a diverting loop colostomy by Dr.
[**Last Name (STitle) **] for a large rectovaginal fistula DISEASE . Intra-operatively she
was noted to have stool in the rectum vaginal and presacral
space and the posterior/presacral space was cleaned out. She
was
discharged on POD#6. It is noteworthy that prior to her
operation she did manifest fever DISEASE and hypotension DISEASE to SBP of 75.
An echocardiogram was reassuring with an EF of 65% with trace
valvular disease DISEASE .

She was evaluated in clinic about two weeks ago by Dr. [**Last Name (STitle) **]
who was not reassured by her progress at that time. She
appeared to be slowly declining with a pelvic choleca situation
which was not amenable to repair due to the prior radiation
damage and poor vascular supply.


Past Medical History:
CAD s/p MI in 94
PVD DISEASE (s/p aorto-fem bypass and L femoral endarterectomy)
L Breast CA s/p mastectomy in early 90's
Colon adenocarcinoma '[** DISEASE 08**] s/p LAR with Chemo and XRT
SBO s/p XLap with LOA in [**3-20**]
Asthma
Hypothyroidism DISEASE
Hyperlipidemia DISEASE
Osteoporosis DISEASE
ORIF R tibia
Bilateral THR [**2110**]
PAF

Social History:
She lives in [**Location 4288**] with her husband. She is a former smoker
but quit 15 years ago. She reports drinking vodka and fruit
juice Admission Date: [**2178-10-16**] Discharge Date:


Service:

CHIEF COMPLAINT: Back pain DISEASE .

HISTORY OF PRESENT ILLNESS: The patient had been
experiencing intermittent back pain DISEASE over the past week who
has a well known history of osteoarthritis DISEASE of the spine. He
was given Percocet for pain DISEASE control without improvement in
his symptomatology. He was seen in the Emergency Room on
[**2178-10-16**] and at that time because of increasing pain DISEASE and drop
in his hematocrit from 30.0 to 20.6. The patient denies any
chest pain DISEASE or short of breath. He is admitted for urgent
repair of a ruptured abdominal aortic aneurysm DISEASE 8 cm in size.

PAST MEDICAL HISTORY: Osteoarthritis T-spine compression
fracture DISEASE .

PAST SURGICAL HISTORY: Right inguinal hernia DISEASE repair.
Vertebral steroid injections.

The patient is a previous smoker.

MEDICATIONS:
1. Zantac.
2. Fosamax.
3. Iron.
4. Percocet.

The patient is not allergic DISEASE to any foods or drugs. Does have
a history of asbestos exposure.

PHYSICAL EXAMINATION: Shows vital signs 96.1 142/86 90
18 room air sat was 96% Head eyes ears nose and throat
exam is unremarkable. There are no carotid bruits DISEASE . Lungs
are clear to auscultation. Heart is regular rate and rhythm.
Abdomen is distended with bowel sounds is nontender. There
is no bruits. Extremities have palpable femoral pulses
bilaterally without distal dorsalis pedis bilaterally. The
rectal exam was guaiac negative.

LABS: Hematocrit of 20.6 with a white count of 16.5 BUN 42
creatinine 1.7. Potassium 4.7. Urinalysis was positive for
nitrates.

Chest x-ray showed bilateral pleural effusions DISEASE with pleural
plaques the right greater than the left.

Electrocardiogram was without acute changes. Normal sinus
rhythm.

The patient was taken to the operating room and underwent
abdominal aortic aneurysm DISEASE repair. He was then transfused 12
units of packed red blood cells and also received 5 units of
FFP and two units of platelets intraoperatively. He remained
intubated was transferred to the SICU for continued
monitoring and care. His SICU course was prolonged and
complicated by respiratory failure DISEASE . He had multiple blood
cultures drawn and urine cultures obtained because of failure DISEASE
to wean. His sputum cultures were on [**10-21**] negative. His
urine culture on [**10-18**] and [**10-16**] were negative. He underwent
a bronchoscopy on [**10-23**] with Endotracheal tube change at that
time. There were no blockages seen vocal cords were normal
and there was mild bronchial edema DISEASE on the mucosa
endotracheal bronchial tree. The right IJ cortise was
converted to a central line on [**10-25**] and required left
subclavian line placement later that day. The patient
remained intubated chest x-ray remained unremarkable except
for the bilateral pleural effusions DISEASE and some basilar
atelectasis DISEASE .

The patient was finally extubated on [**2178-10-28**]. Physical
therapy was requested for evaluation. During this period in
SICU the patient required TPN and tube feed support.

On [**2178-10-30**] the patient passed flatus and had a bowel
movement. He was then at that time transferred to MICU for
continued monitoring and care.

On [**11-5**] the left subclavian line was changed to left IJ. He
was begun on p.o.'s and diet advanced as tolerated. The TPN
and tube feeds were discontinued after caloric intake was
evaluated.

On [**2178-11-8**] the patient became tachypneic DISEASE and tachycardiac.
Electrocardiogram was without acute ischemic changes. A
chest x-ray was unchanged. The chest CT was negative for
pulmonary embolism DISEASE . Abdominal CT showed distended
gallbladder. His liver function tests were elevated with an
ALT of 94 AST 81 Alk phos 293 total bili 6.9 Lipase 73
amylase 106 lactate was 1.8 blood gases 7.38 31 99 and 13
with an elevated white count of 33.0 with a T-max of 102.6.
The patient required re-intubation and transfer to the SICU.
Gastrointestinal was consulted. An ultrasound of the
gallbladder was obtained and needle aspirate was done. The
patient was empirically begun on Unasyn. The cultures of the
blood urine sputum and gallbladder were no growth. The
Infectious Disease DISEASE was consulted at this time. He was
empirically started on Unasyn Vancomycin and Flagyl. CK and
Troponin levels were obtained and they were flat.

On [**11-10**] the patient was extubated without incident and the
right subclavian line was changed. Cultures were sent to the
line at this point of the dictation are no growth but not
finalized. Vancomycin was discontinued. Oxacillin was begun
on [**2178-11-11**] 2 grams q 6 hours for suspected line sepsis DISEASE . The
Nasogastric tube was removed. His diet was advanced as
tolerated on [**2178-11-12**]. PICC line was placed and the central
line was discontinued. He received two units of packed cells
for hematocrit. Oxacillin was started for the enterococcus
which was 10000 to 100000 organisms in his urine culture
and sensitivity on [**2178-11-8**].

The transfusion was for a hematocrit of 26.7 he received two
units. His post transfusion crit was 33.3.

The patient continued to do well. Physical therapy continued
to work with the patient. Recommended rehabilitation and
case management was requested to screen the patient
appropriate facilities.

At the time of discharge the patient's wounds were clean dry
and intact. He was medically stable.

DISCHARGE MEDICATION:
1. Albuterol multidose inhaler puffs two q 4 hours.
2. Insulin sliding scale glucose of less than 60 no
insulin glucoses 131 to 151 one unit 151 to 200
two units 201 to 250 4 units 251 to 300 6 units
301 to 350 8 units 351 to 400 10 units greater than
400 12 units and call.
3. Heparin subcutaneously b.i.d.
4. Boost with meals.
5. Vioxx 25 mg q day.
6. Lasix 20 mg q day.
7. Lopressor 37.5 mg b.i.d.
8. Albuterol Atrovent nebulizer treatments q 4 hours p.r.n.
9. Oxacillin 2 grams intravenous q 4 hours for a total of
two weeks.

FOLLOW-UP: Patient should be seen by Dr. [**Last Name (STitle) **] in two
weeks post discharge.

DISCHARGE DIAGNOSIS:
1. Ruptured abdominal aortic aneurysm DISEASE with repair.
2. Metabolic acidosis DISEASE etiology undetermined corrected.
3. Respiratory failure DISEASE requiring prolonged intubation
extubated stable.






4. Blood loss anemia DISEASE transfused corrected.
5. Enterococcus urinary tract infection treated.







[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**] M.D. [**MD Number(1) 6223**]

Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36

D: [**2178-11-15**] 16:59
T: [**2178-11-15**] 16:57
JOB#: [**Job Number 6224**]
Admission Date: [**2107-3-3**] Discharge Date: [**2107-3-17**]

Date of Birth: [**2056-9-8**] Sex: F

Service:

ADMISSION DIAGNOSIS: Abdominal pain DISEASE

DISCHARGE DIAGNOSIS:
1. Mitral valve regurgitation DISEASE
2. Congestive heart failure DISEASE
3. Status post mitral valve repair

HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
black woman who reported sudden onset of abdominal pain DISEASE
approximately one week ago. Abdominal pain has been steadily
worsening and the patient reports no change in bowel
symptoms. The patient has had a decrease in appetite and
sudden increase in shortness of breath DISEASE . The pain DISEASE is
epigastric in nature and crampy. The patient was admitted
for workup of her abdominal pain DISEASE .

PAST MEDICAL HISTORY: 1. Morbid obesityAdmission Date: [**2193-7-13**] Discharge Date: [**2193-7-18**]

Date of Birth: [**2157-7-20**] Sex: M

Service: MED

Allergies DISEASE :
Phenobarbital / Valium / Haldol

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Constipation DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
35 yo male with mental retaration and chronic consipation (does
not verbalize Mother takes care with him.) p/w 3 weeks history
of constipation DISEASE and recent dystonic reaction DISEASE to Haldol treated
with Ativan. Two weeks prior to visit pt was oozing DISEASE fecal
matter per rectum according to mother. sx of restlessness
generalized pain DISEASE
rubbing head and ears stomach is distended pt having trouble
walking Pt is retarded and can not verbalize his symptoms.
Referred back to [**Hospital1 DISEASE 18**] ER. Pt has a history of severe
constipation DISEASE only fully dissolved with fecla disimpaction.
Patient recently returned from [**State 1727**]. Mother reports BM T this
am Wed [**Name (NI) 5929**]. Giaiac Neg in ED.

Past Medical History:
mental retardation
seizure DISEASE disorder(Grand mal seizure DISEASE [**Month (only) 205**] l993. He has
been on Dilantin since and has had no further seizure DISEASE
activity)
hypertension DISEASE
history of sinusitis DISEASE
[**Last Name (un) 6226**]-[**Last Name (un) 6227**] disease
history of developmental delay


Social History:
mentally retarded and lives w/ family

Family History:
n/c

Physical Exam:
VSS T 100.4 Admission Date: [**2138-7-25**] Discharge Date: [**2138-9-4**]

Date of Birth: [**2072-7-20**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory Failure DISEASE

Major Surgical or Invasive Procedure:
Tracheostomy
Intubation
R Thoracentesis (x2)
Central Line Placement
PICC Line Placement
HD DISEASE line placement
Hemodialysis (CVVH)
PEG Placement


History of Present Illness:
61 year old man PMH of DM type II with recent hospital
admission ([**5-22**]) for enterococcal bacteremia DISEASE and aortitis DISEASE
presented to OSH on [**2138-7-22**] complaining of 6 weeks of back pain DISEASE
and bowel incontinence DISEASE . Patient said onset of severe back pain DISEASE
began approximately 6 weeks ago in lower right side worse with
sitting or standing. If attempted to stand he experience pain DISEASE
shooting up his back. He last walked approximately 6 weeks ago.
The pain DISEASE has been stable not worsening. He reports mild
improvement. He is now able to roll in bed. Yesterday patient
was unable to turn his head to the side. That has since
resolved.
.
Two weeks ago patient developed bowel incontinence DISEASE . He can not
sense when he is going. He has loss of stool approximately
3-4x/day. Also reports decreased urine output with no leakage or
dribbling. Patient feels he is dehydrated.
He decided to go to the hospital when after attempting to get
out of bed he felt very dizzy and Admission Date: [**2160-12-17**] Discharge Date:

Date of Birth: Sex: M

Service:
HISTORY OF PRESENT ILLNESS: This is a 54-year-old gentleman
with past medical history significant for end stage renal
disease peritoneal dialysis times one year status post
glomerular nephritis DISEASE and renal transplant times three and
aortic valve replacement secondary to calcific DISEASE aorta who
admission also comes in with a little bit of back pain DISEASE and
some chills DISEASE . She denied any localizing symptoms no cough DISEASE
no chest pain DISEASE no shortness of breath no abdominal pain DISEASE no
flank pain DISEASE . He did have some mild nausea DISEASE earlier the day of
admission which seemed to have resolved. He called his
primary care physician and was told to go to the Emergency
Room. The day prior to admission the patient had an MRA to
and third finger on his right hand.

PAST MEDICAL HISTORY: Included end stage renal disease DISEASE
status post peritoneal dialysis times one year post
glomerular nephritis renal transplant DISEASE times three chronic
anemia hypertension DISEASE aortic valve replacement secondary to
calcific aorta otitis DISEASE and GI polyps DISEASE .

MEDICATIONS: Prednisone 3.75 mg q d Atenolol 25/50
RenaGel TUMS aluminum hydroxide Prilosec Coumadin 5 mg
and 3 mg alternating.

ALLERGIES: Captopril which gave him a rash DISEASE and talcum
powder.

FAMILY HISTORY: Significant for father having esophageal
carcinoma DISEASE . Patient denied any alcohol or drug use. No
smoking history. Occupation: Patient is a plastic surgeon
and was practicing doing his surgery two weeks prior to
admission.

PHYSICAL EXAMINATION: In the Emergency Room included a
temperature of 101.7 heart rate 112 blood pressure 153/112.
This is a pleasant white man lying in bed appeared pretty
sick looking. HEENT: Pupils are equal round and reactive
to light and accommodation. Oropharynx was clear. Anicteric
sclera. Neck was supple no lymphadenopathy DISEASE . Chest was
clear to auscultation bilaterally. Cardiovascular was tachy
regular rate and rhythm grade 3/6 systolic ejection murmur
heard best at the apex. GI was soft nontender non
distended normoactive bowel sounds. GU no CVA tenderness DISEASE
no flank pain DISEASE . Musculoskeletal: Patient had right second
and third finger ischemic at the fingertips otherwise no
cyanosis DISEASE no clubbing DISEASE no edema DISEASE . Skin with no evidence of
any rashes. Neuro patient was alert oriented.

LABORATORY DATA: On admission included a white count of
12.6 hematocrit 29.4 platelet count 91000 Chem 7 of
138/4.9 99/25 BUN and creatinine 48/13.4 glucose 91
calcium 9.1 phosphorus 4.0 magnesium 1.7. Differential on
the white count was 71% polys 10% bands 14 lymphs no eos
no basos. Peritoneal fluid had two white cells 19 RBC 60
PMNs 30 lymphs 20 monos. Gram stain with no PMNs no
organisms. Urinalysis cannot be done because patient did not
make any urine. Chest x-ray was clear on admission.

HOSPITAL COURSE: On [**12-18**] the patient had some respiratory
failure DISEASE and hypotension DISEASE . As patient developed fevers DISEASE
chills DISEASE with no obvious source of infection DISEASE but developed
some hypoxia DISEASE overnight was on nasal cannula however in the
morning had increased respiratory rate and decreased O2 saturations with PH of 7.16 and increasing somnolence DISEASE . The
patient had CT scan to evaluate his questionable abdominal
source however the patient was then admitted to the medical
ICU because he became hypotensive DISEASE in the 70's but responded
to minimal IV fluids. The patient was started on some
Vancomycin Gentamycin and Flagyl for his ongoing fevers DISEASE . In
the medical ICU the patient was noted to be hypotensive DISEASE and
also with an increased metabolic acidosis DISEASE probably secondary
to sepsis DISEASE . The patient was started on some Neo-Synephrine
and Levophed for aggressive blood pressure control as well as
some aggressive fluid management. The patient also started
on Levofloxacin for coverage and antibiotics. The patient
was then on Levo Flagyl Gent and Vancomycin. The patient
also was found to be in DIC with an elevated PT PTT. If the
platelets were lower the patient needed to receive some
fresh frozen plasma anticoagulation factors as well as some
platelets for this support. The patient had right groin line
placed as well as a left femoral line placed and some
peripheral IVs as well. Later on that evening at 4:30 p.m.
on [**1-18**] the patient became bradycardic with heart rate in the
30's with a low blood pressure. The patient was given
Atropine .5 mg an amp of Epi with resolving of increased
heart rate blood pressure and patient was also given Calcium
and some bicarb. Then patient went into VT with the rate at
about 200 was shocked about 200-300 joules and then was back
in sinus rhythm with rate of 140 with a little bit of
hypotension DISEASE . The patient had his electrolytes repleted. The
patient was found to be over breathing the ventilation with
high respiratory rates despite the sedation with Fentanyl and
Ativan. Therefore patient was paralyzed to maximize
ventilation. The patient was also changed off the different
pressors with Levophed and Vasopressin. The patient was then
given hemodialysis instead of his peritoneal dialysis for the
next couple of days. The patient was continued on his
antibiotic regimen of Ceftriaxone Vancomycin Levofloxacin
Flagyl DISEASE as well as Vancomycin for his unknown source. The
patient then had a pulmonary bronchoscopy to evaluate to see
if there is any bacterial pneumonia DISEASE but the patient had no
evidence of anything on bronchoscopy. Bronchial alveolar
lavage was done which in turn was negative. The patient also
had a TEE for further evaluation with questionable
endocarditis DISEASE however no vegetations DISEASE were seen on the
patient's aortic valve. The patient was cultured numerous
times in terms of his blood cultures as well as sputum
cultures as well as peritoneal dialysis fluid however no
source ended up ever growing out anything.

COMPLICATED MEDICAL ICU COURSE:
1. ID: Septic shock DISEASE . Etiology of the septic shock DISEASE was not
entirely clear as chest x-ray CT scans were just compatible
with ARDS DISEASE and multifocal pneumonia DISEASE . However no bug ever
grew out. The patient was continued on Vancomycin
Gentamycin Levofloxacin Ceftriaxone. TEE was performed to
rule out endocarditis DISEASE however was negative. The patient
was continued on various pressors to support his blood
pressure given the septic DISEASE picture such as Levophed and
Vasopressin. As the patient remained in house the patient
ended up developing some C. diff colitis DISEASE probably secondary
to all the antibiotics he was on. The patient was given a 10
day course of po Vancomycin per his NG tube as well as being
continued on the other antibiotics. The patient had his
peritoneal dialysate fluid as well as various sputum cultures
and blood cultures sent for any temperature spike that he had
had. Nothing had ever grown out of any of these cultures.
The patient was continued on Levofloxacin Flagyl Vanco
Gentamycin for 14 day course total. The patient had all his
medications renally dosed as patient has end stage renal
disease. The patient had various tipped catheters of his
central lines changed over wires as well as re-sited and tips
were sent for culture however nothing ever grew out as
well. The patient had CT scan of his abdomen times two which
revealed a left iliopsoas abscess which eventually was
drained however no bug or any white cells were found in
that abscess. As well patient had evidence on abdominal CT
scan of an enlarged gallbladder which was drained however
just revealed normal biliary substances with no bacteria no
PMNs. The only thing that ever grew back besides the C. diff
colitis DISEASE was a sputum culture that was positive for MRSA on
[**1-15**]. The patient had various other negative blood cultures
sputum cultures as stated before under the ID aspect of this.

2. Renal: The patient was end stage renal disease DISEASE was
started on hemodialysis as he first was admitted to the
Medical Intensive Care Unit however eventually the patient
went over to peritoneal dialysis as he did at home. The
patient was continued pretty much on his outpatient regimen
however while on dialysis the patient developed some glucose
intolerance from the high Dextrose levels found in the
peritoneal dialysis fluid. The patient was started on an
insulin drip and blood sugars were monitored closely while
patient was on peritoneal dialysis requiring different
insulin doses daily. Eventually patient was placed on an NPH
dose as well as insulin being added to his peritoneal
dialysis fluid. Currently patient is pretty much on his own
home dialysate as well as home dialysis schedule.

3. Respiratory: Patient was ventilator dependent on
admission to medical ICU on [**12-18**]. The patient remained on
the ventilator for full support until finally extubated on
[**2161-1-15**]. The patient was very much sedated from all the
medications that we gave him including Fentanyl Ativan as
well as paralysis DISEASE . So it took awhile to wean the patient of
the ventilator due to the excessive sedation. However
patient finally weaned on [**1-15**] while minimal Fentanyl and
Ativan drips which eventually were shut off and was able to
sat well on nasal cannula O2 as well as a face mask. After
patient was admitted to the Medical Intensive Care Unit and
ventilated the patient developed an ARDS type of picture and
he was vented in a way to keep his total volumes low for
decreased lung injury DISEASE . The patient remained on the
ventilator as I stated before until [**1-15**] when he was
extubated and patient had some satting.

4. GI: As stated before the patient had C. diff cultures
which eventually were positive. The patient was started and
completed a 14 day regimen of po Vancomycin and eventually
had a repeat C. diff culture which was negative. The patient
also developed evidence of some lower GI bleed DISEASE as well as he
has had melenic stools as well as an upper GI bleed with
positive NG lavage. The patient had a colonoscopy done while
in house on [**1-19**] which showed some evidence of some ischemic
colitis DISEASE as well as a couple of polyps. The patient had some
Epinephrine injected into the part of the colon which was
actively bleeding DISEASE at the time. The patient's hematocrit
remained stable after that and evidence of the GI bleed DISEASE
seemed to have decreased. The patient had evidence of some
pancreatitis DISEASE with rising amylase and lipase levels which
probably was attributed to his septic DISEASE picture. The patient
also had a minimal elevation in his LFTs but with
normalization of his total bilirubin and his alkaline
phosphatase therefore it was thought that this was due to
sepsis DISEASE rather than a primary source of the gallbladder at the
time until patient finally had the gallbladder drained which
revealed that it was indeed just due to his npo status and
having an enlarged gallbladder rather than having infectious
cholangitis DISEASE or such.

5. Heme: Patient was admitted to the Medical Intensive Care
Unit in sepsis DISEASE . The patient was in a DIC type of picture.
The patient required excessive platelets as well as blood
transfusions as well as other coagulation factors for support
of his DIC picture. The patient also had to be on Heparin
for an AVR replacement which he had had done previously so
PTT was monitored pretty closely.

6. Cardiovascular: The patient had a history of
hypertension DISEASE when he came in. He was on Atenolol. The
patient needed aggressive pressor support as well as fluid
boluses to maintain his blood pressure while he was in the
septic DISEASE picture. The patient was on Neo-Synephrine as well as
Levophed as well as some Vasopressin for support of his blood
pressure control. The patient was weaned off of all pressors
on [**1-11**] and was hemodynamically stable not requiring anymore
pressor support. Blood pressure at times was maintained with
some fluid boluses as patient sometimes got a little bit
hypotensive DISEASE while he started peritoneal dialysis. However
that seemed to have resolved as we changed his peritoneal
dialysate to make his fluid status pretty much even.

7. Fluids Electrolytes & Nutrition: The patient was
started on TPN while in house and after extubation patient
was on tube feeds. The patient has been tolerating tube
feeds well started on Neo-Pro for further nutrition while on
tube feeds. He was started on Criticare and tolerated it
well.

8. Endocrine: The patient had evidence of glucose
intolerance secondary to the high Dextrose as well as the
sepsis DISEASE picture as well as the chronic Prednisone that
patient was taking at home. The patient was started as I
said before on an insulin drip which was titrated to keep
his blood sugars tightly controlled between 90 and 110
however eventually patient was weaned off the insulin drip
and was given NPH insulin as well as insulin and his PD fluid
for better blood glucose control. Currently patient was
getting the insulin and the PD fluid as well as sliding scale
for control with fingersticks checked every two hours while
undergoing the peritoneal dialysate. The patient was
continued on stress dose steroids for the chronic Prednisone
he took at home. He was started on 100 mg qid of Hydrocort
and eventually was weaned down to 15 mg tid of Hydrocort and
eventually 10 mg of Prednisone.

9. Musculoskeletal/Neuro: The patient was paralyzed after
the intubation as the patient got hypotensive DISEASE as well as
patient was given high dose steroids. The patient after
being taken off the paralysis DISEASE and being tailored down on the
steroids the patient continued to be extremely weak and
fairly less spontaneous movements. After extubation the
patient slowly gained a little bit of strength back as the
Fentanyl and Ativan were wearing down as well as stronger as
when he was having some physical therapy. The patient
remained extremely weak had very little spontaneous
movements and difficulty speaking. The patient will need
aggressive physical therapy to get back to his baseline as
patient is a plastic surgeon and was fully active prior to
coming into the hospital.

I will update any further events that occur after this
dictation on an addendum and will summarize the ID course at
that seems to have been his major issue during this
admission.




DR.[**First Name (STitle) **][**First Name3 (LF) **] 11-647

Dictated By:[**Last Name (NamePattern1) 6234**]

MEDQUIST36

D: [**2161-1-22**] 13:09
T: [**2161-1-24**] 09:37
JOB#: [**Job Number 6235**]
Admission Date: [**2160-12-17**] Discharge Date:

Date of Birth: [**2106-1-16**] Sex: M

Service:

ADDENDUM:

Under the neurologic aspect of his care in the Medical
Intensive Care Unit the patient was on high dose paralytic DISEASE
as well as some high dose steroids. The patient continued to
be lethargic with decreased movement of his upper extremities
as well as lower extremities.

The patient had a head CT which was unequivocal for any
findings other than slight sinusitis DISEASE . The patient also had a
magnetic resonance scan of his head and his spine to evaluate
if there was any central process causing his upper and lower
extremity weakness DISEASE . Both the CT scan as well as the magnetic
resonance scan of the head as well as the magnetic resonance
scan of the neck revealed no central process that causes
extensive motor weakness DISEASE .

Neurology was consulted and attributed this to be a critical
care neuropathy DISEASE . An EMG DISEASE was also performed which only
revealed that it was neuropathy DISEASE however the patient was
very sedated at the time and it was not the best time to
perform it because the patient was under high dose sedation.
However according to neurology it was very likely to be a
Intensive Care Unit neuropathy DISEASE and the patient will
eventually regain his strength as high dose paralytics as
well as high dose steroids as well as the stress from being
in sepsis DISEASE alone will hopefully wear off and the patient will
regain his strength hopefully to his full ability.

The patient's mental status apparently was normalized towards
the end of the admission as the patient was responding
appropriately with head nods as well as minimal spontaneous
movements of his upper and lower extremities. The patient
was also able to attempt to speak and was able to talk with
us although be it extremely difficult for the patient due to
his weakness and was able to talk and let us know exactly
what was bothering him.

We will add more to this dictation summary as his long and
extensive hospital course continues.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**] M.D. [**MD Number(1) 1212**]

Dictated By:[**Last Name (NamePattern1) 6234**]

MEDQUIST36

D: [**2161-1-22**] 13:19
T: [**2161-1-24**] 10:14
JOB#: [**Job Number 6236**]
Admission Date: [**2161-9-25**] Discharge Date: [**2161-10-5**]

Date of Birth: [**2106-1-16**] Sex: M

Service: COLORECTAL

ADMITTING DIAGNOSIS:
1. End-stage renal disease DISEASE .
2. Adult respiratory distress syndrome DISEASE .
3. Severe colitis DISEASE .
4. Fatal arrhythmia DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 54 year old
male with end-stage renal disease DISEASE secondary to
post-Streptococcal glomerular nephritis DISEASE and CPDD and adrenal
insufficiency who presented with two to three weeks of lower
abdominal pain DISEASE and was found to be Clostridium difficile DISEASE
positive. Upon work-up the patient showed worsening
abdominal CT scan consistent with pan-colitis.

The patient was initially treated with Vancomycin
intravenously with p.o. Ciprofloxacin and Flagyl. On
[**2161-9-28**] the patient was found to be gasping for air while
on 100% non-rebreather mask with an arterial blood gases of
7.04 80 43. The patient was immediately intubated and
admitted to the Surgical Intensive Care Unit at which time
the patient was found to have atrial fibrillation DISEASE with heart
rate between 100 to 140. Rate was very difficult to control
and Diltiazem drip was initiated.

On [**2161-9-27**] the patient's heart rate remained
between 90 to 110 with Diltiazem drip at 10 mg per hour and
blood pressure was also difficult to maintain. The patient
responded well initially to boluses with decrease in
tachycardia DISEASE however due to the worsening pan-colitis the
patient was taken back to the Operating Room for a subtotal
colectomy.

PHYSICAL EXAMINATION: N/A.

SUMMARY OF HOSPITAL COURSE: The patient is a 55 year old
male status post subtotal colectomy and end-ileostomy for
infarcted small intestine DISEASE and colitis DISEASE with pseudomembranes DISEASE .
The patient was initiated on broad-spectrum antibiotics with
cultures sent. The patient's CT scan of the abdomen
indicated a diffuse thickening of terminal ileum DISEASE and large
intestine to the transverse colon without stranding.

A repeat CT scan immediately prior to the subtotal colectomy
indicated pan-colitis which progressed from prior scan but no
evidence of perforation DISEASE .

Immediately postoperatively the patient continued to have
respiratory distress DISEASE requiring increased pressor support and
required continued transfusion with seven units both of P
two units of packed red blood cells and four liters of
Crystalloid.

Despite the continued resuscitation the patient remained
hypotensive DISEASE with continued lactic acidosis DISEASE requiring
bicarbonate replacement. The aggressive resuscitation
continued until [**2161-10-5**] when after a long
discussion with the family members the patient was made
comfort measures only.

The patient developed a ventricular fibrillation DISEASE shortly
thereafter and expired later on that evening.

DISCHARGE DIAGNOSES: Status post subtotal colectomy and
ileostomy.

DISPOSITION: Death DISEASE .


[**Last Name (NamePattern4) 1889**] M.D. [**MD Number(1) 1890**]

Dictated By:[**Name8 (MD) 6247**]
MEDQUIST36

D: [**2162-2-28**] 12:11
T: [**2162-2-28**] 16:26
JOB#: [**Job Number 6248**]
Admission Date: [**2174-5-3**] Discharge Date: [**2174-6-3**]

Date of Birth: [**2110-2-28**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Ciprofloxacin

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
found down

Major Surgical or Invasive Procedure:
Left craniotomy


History of Present Illness:
In brief this is a 64 yo M with hx of melanoma DISEASE s/p craniotomy
and resection of metastatic melanoma DISEASE in brain. He was initially
admitted after found down on [**5-3**]. Had multiple intraparencymal
hematomas SAH DISEASE SDH. Underwent resection of tumor DISEASE and cyst
cavities on [**5-6**]. S/p craniotomy which was done on [**5-6**] he has
been aphasic DISEASE and had ongoing myoclonic seizures DISEASE . He was
monitored on EEG and last seizure DISEASE was 3 days ago thought to be
in setting of sepsis DISEASE and lowered sz threshhold. He is currently
on max doses of dilantin and Keppra and being followed by neuro
for AED recommendations. He was transferred to MICU for
management of septic shock DISEASE after blood cx grew enterobacter
cloacae (possibly spread from urine). He was on CTX but
currently on meropenem afebrile and no leukocytosis. He has a
PICC line in place for a 14-day course of meropenem. LP was done
in MICU and was normal. Throughout the MICU stay he has been
tachycardic with a fib and flutter DISEASE intermittently on tele. On
[**5-15**] he was ruled out for PE with negative CTA and LENIs. He
responds to fluids and HR is currently in the 90s on PO
diltiazem and metoprolol. [**Name (NI) **] sister is his HCP and has
recently made him DNR/DNI she would like to discuss goals of
care with the primary team. Neuro-oncology has been following
and he may require XRT but there has been some discussion of his
current poor performance status limiting gains of further
therapy.

ROS: as in HPI


Past Medical History:
HTN DISEASE Hypercholestolemia lung CA Asthma Depression DISEASE

Social History:
He is divorced and lives alone. He is a hairdresser on
disablity for the past seven years. He is a heavy smoker. He has
one brother and one sister both are healthy. He has no
children. His health care proxy is her sister [**Name (NI) **]Admission Date: [**2102-1-17**] Discharge Date: [**2102-1-31**]


Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Nausea distention DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 6249**] is a [**Age over 90 **] year-old male with a history of
diverticulitis DISEASE s/p Hartmann's procedure in [**5-11**] and who most
recently is s/p exploratory laparotomy with LOA in [**11-12**] which
has been complicated by prolonged ileus DISEASE and presented to [**Hospital1 18**]
on [**2102-1-17**] for evaluation and treatment.

Past Medical History:
As above including: htn diverticulitis sigmoid volvulus DISEASE
SBOs COPD DISEASE

PSH DISEASE : likely L colectomy hartmanns [**5-11**] ostomy takedown [**8-11**]
internal hernia DISEASE w/ SBO 1 week later s/p exlap loa repair
incisional hernia DISEASE repair [**4-11**]


Social History:
Married with four children. Former owner of restaurant. Former
smoker.

Physical Exam:
Alert no distress
Decreased [**Last Name (un) 6250**] sounds at lung base
RRR
Abd distended soft nontender

Brief Hospital Course:
Mr. [**Known lastname 6249**] is a [**Age over 90 **] year-old male with a history of
diverticulitis DISEASE s/p Hartmann's procedure in [**5-11**] and who most
recently is s/p exploratory laparotomy with LOA in [**11-12**] which
has been complicated by prolonged ileus DISEASE and presented to [**Hospital1 18**]
on [**2102-1-17**] for evaluation and treatment. He was admitted to the
surgery service. A rectal tube was placed. On [**1-18**] Mr.
[**Known lastname 6249**] was found to be in respiratory distress DISEASE and was
intubated. CXR revealed atelectasis DISEASE and infiltrate. A CT torso
revealed no evidence of sbo but a fluid filled sigmoid. He was
continued on antibiotics. He was started on neostigmine. He
was extuabated two days later and would remain stable from a
respiratory standpoint. He was transferred to the floor in
stable condition. Success was achieved with a combination of
prokinetics and dulcolax and his bowel functioned returned. He
was started on oral pyridostigmine and reglan. He began
tolerating a regular diet and by the time of discharge he was
taking in an adequate amount of oral intake. The rectal tube
was removed. He was discharged to rehab in good condition on
[**2102-1-31**] tolerating a regular diet having bowel movements DISEASE and
with less abdominal distention DISEASE . He should receive dulcolax for
constipation DISEASE or abdominal distention DISEASE . A rectal tube as well
should be placed for marked distention.

Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed for Wheezing DISEASE .

2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea DISEASE .
3. Heparin (Porcine) 5000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Camphor-Menthol 0.5-0.5 % Lotion DISEASE Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp Admission Date: [**2155-9-16**] Discharge Date: [**2155-9-19**]

Date of Birth: [**2073-2-20**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Doctor First Name 1402**]
Chief Complaint:
Ventricular tachycardia DISEASE

Major Surgical or Invasive Procedure:
-VT ablation
-ICD generator change


History of Present Illness:
This morning the patient was having breakfast when he heard a
loud banging noise DISEASE and dropped his cup of tea. This episode was
not accompanied by any other symptoms. The patient denied any
chest pain DISEASE . His baseline does involve symptoms of exertional DISEASE
dyspnea DISEASE with moderate physical activity but no symptoms of
dyspnea DISEASE at rest orthopnea DISEASE paroxysmal nocturnal dyspnea DISEASE (he
consistently sleeps on two pillows) or lower extremity edema.
He has not had any episodes of dizziness DISEASE or syncope DISEASE .
.
The patient reported for a routine ICD outpatient check and was
discovered to be in sustained ventricular tachycardia DISEASE at about
160-170 beats per minute. The patient's son was told that the 4
shocks in the recent pastAdmission Date: [**2121-5-10**] Discharge Date: [**2121-5-12**]

Date of Birth: [**2067-11-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Hypotension DISEASE

Major Surgical or Invasive Procedure:
R IJ central line placement


History of Present Illness:
Briefly this is 53 yo M s/p DDRT in [**2111**] who was in his usal
state of health until 2 days prior to presentation when he
develped non-bloody diarrhea DISEASE and non bloody non-bilious emesis DISEASE .
No sick contract no travel no abnormal food exposure and no
recent antibiotic exposure. He reports lightheadedness and
dizziness DISEASE and 2 syncopal DISEASE episodes.
.
In the emergency department he was found to be hypotensive DISEASE with
BP 70/40 (baseline SBP Admission Date: [**2122-1-5**] Discharge Date: [**2122-1-24**]

Date of Birth: [**2067-11-18**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Right leg pain DISEASE and swelling DISEASE

Major Surgical or Invasive Procedure:
Temporary IVC filter placement
Esophagogastroduodenoscopy
colonoscopy


History of Present Illness:
54 y.o. male with PMHx of ESRD DISEASE (thought to be [**3-14**] HTN DISEASE ) s/p
deceased donor kidney transplant in [**2111**] HTN DISEASE and gout DISEASE who
presented to the ER with right leg swelling and pain DISEASE x 3 days.
He denies any recent injury or prolonged travel and has not had
problems with leg swelling DISEASE in the past. He additionally denies
SOB or CP. In the ED patient was evaluated and noted to have a
tender erythematous right LE with a right calf measuring 43cm
compared to 38 cm of the left calf. Bilateral LE dopplers were
performed and showed a DVT DISEASE in the right common femoral to the
calf veins. Given his kidney disease DISEASE renal transplant was
consulted in the ED and felt there were no active transplant
issues. Patient was noted to be guaiac positive and does have a
history of a colonic polyp DISEASE found in [**2119**]. A Heparin gtt was
started and the patient was admitted for further management.


Past Medical History:
ESRD DISEASE Admission Date: [**2191-4-18**] Discharge Date: [**2191-5-10**]

Date of Birth: [**2112-3-14**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Ceftriaxone

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Pneumonia DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a 79 yo recently diagnosed with [**Doctor Last Name 6261**] syndrome
(transformation of CLL DISEASE to large B cell NHL) now s/p 3 cycles of
CHOP presents with PNA diagnosed at [**Hospital1 **] ED. The pt is
now referred from [**Hospital 478**] clinic for treatment of PNA. The pt
presented to OSH ED on [**4-13**] and was diagnosed with LLL PNA and
was given a course of levofloxacin. The pt did not take his abx
as prescribed. He c/o increased SOB DOE and cough DISEASE x 1 week.
The pt also c/o decrease appetite over past week with 4 lb
weight loss DISEASE . No increase in fatigue DISEASE . No f/c/s n/v d/c
abdominal pain chest pain DISEASE or pain DISEASE with inspiration.

Past Medical History:
1) CAD
2) HTN DISEASE
3) Dyslipidemia DISEASE
4) PVD DISEASE s/p PTCA RCI/LCI/LEI stenting and fem bypass
5) Arthritis DISEASE
6) h/o CVA DISEASE while on ASA/plavix
7) BPH
8) Early Parkinson's Disease DISEASE
.
Onc History:
subcarinal LAD noted on bronchscopy in [**1-23**] which was negative
for malignant cells. Referred DISEASE by Dr. [**First Name (STitle) 1313**] to heme onc for
enlarged lower lobe lung mass. Mediastinoscopy was performed in
[**11-22**] which was suggestive of atypical chronic lymphocytic DISEASE
leukemia DISEASE . Lung biopsy performed revealed a large Bcell NHL DISEASE . The
probable basis for his problem is understood to be
transformation of CLL DISEASE to a [**Doctor Last Name 6261**] syndrome. s/p 3 cycles of
CHOP
.
Lymph Node bx [**11-22**]:
Immunophenotypic findings are of involvement by a
lambda-restricted CD5 positive B-cell lymphoproliferative
disorder. The differential diagnosis includes an atypical
chronic lymphocytic leukemia DISEASE (with subset loss of CD23).
.
CT [**2191-4-5**]:
1. Unchanged size of left lower lung lobe mass measuring
approximately 7.4 cm in greatest axial dimension DISEASE . This mass has
decreased attenuation when compared with the prior exam which
may be secondary to chemotherapy treatment and necrosis DISEASE . Small
pulmonary nodules in the lower lobes bilaterally are unchanged.


Social History:
Quit smoking [**2150**] smoked 1.5 ppd x 20 yrs. [**12-20**] glasses
wine/day. lives alone at [**Location (un) 2725**].


Family History:
Mother died of CVA DISEASE also had h/o stomach and intestinal cancer DISEASE
Father died of CVA DISEASE
Sister died of lung cancer DISEASE

Physical Exam:
VS: T 97.3 P 99 BP 130/68 R 20 Sat 85-88%RA
Gen: AAO times 3
HEENT: NCAT PERRL conjunctivae anicteric/noninjected MMM OP
clear
Neck: JVP 7 cm
CV: RRR nS1S2 no r/m/g
Pulm: diffuse ronchi
Abd: soft NT/ND DISEASE without masses or bruits NABS no palpable HSM
Ext: 1Admission Date: [**2145-5-25**] Discharge Date: [**2145-5-31**]

Date of Birth: [**2091-12-30**] Sex: F

Service: [**Location (un) 259**]

CHIEF COMPLAINT: Status post right middle lobe bronchus
stent removal with hemoptysis/airway secretion.

HISTORY OF PRESENT ILLNESS: This 53-year-old female with
past medical history significant for Stage III-B nonsmall cell lung cancer DISEASE diagnosed in fall of [**2142**] with recurrent C
Factor VIII deficiency and epilepsy DISEASE who presents with
hemoptysis DISEASE and excessive secretions status post right main
bronchus stent removal. Originally patient was diagnosed
with nonsmall cell lung cancer DISEASE in fall of [**2142**] and was
treated with XRT and chemotherapy with carboplatin and Taxol.
Her disease reoccurred in [**2143-5-5**] and she was again
treated with XRT with minimal response. The lung cancer DISEASE had
then progressed.

On [**2145-5-3**] the patient underwent bronchoscopy (via cytology
revealed nonsmall cell lung cancer DISEASE ) with stent placement in
the bronchus intermedius. Poststent CT demonstrated adequate
placement. However the patient was unable to tolerate the
stent with persistent cough DISEASE and increased secretions. She
presents today for elective stent removal. The procedure was
complicated by 150 cc of hemoptysis DISEASE poststent removal which
was controlled with suctioning and airway protection.

On arrival the patient complains of shortness of breath DISEASE with
increased nonbloody secretions which is improved with
nebulized lidocaine. She also complains of mild anterior
right chest discomfort which is chronic and pleuritic. She
denies any nausea vomiting headache chills DISEASE .

PAST MEDICAL HISTORY:
1. Stage III-B (T4 M0 N0) nonsmall cell lung cancer DISEASE diagnosed
in fall of [**2142**] treated with carboplatin/Taxol induction with
low dose XRT. She also had a second XRT treatment in [**2143-5-5**] and had suffered some radiation pneumonitis DISEASE .
2. Catanenial epilepsy DISEASE treated in [**2134**].
3. Factor VIII deficiency.

MEDICATIONS AT HOME:
1. Klonopin 0.25 mg po q4h 0.5 mg po q hs.
2. Estrogen 0.3 mg po q day.
3. Progesterone 200 mg po q day.
4. Albuterol prn.

ALLERGIES: Chemical sensitivity to quinolones macrolides
aspirin nonsteroidal anti-inflammatories and penicillin.
She develops hives with levofloxacin.

SOCIAL HISTORY: She is married with two children. She has a
30 pack year smoking history who quit in [**2142-9-4**].

FAMILY HISTORY: Mother with lung cancer DISEASE and hemophilia DISEASE
maternal grandmother with breast cancer DISEASE .

PHYSICAL EXAM DISEASE UPON ADMISSION: Vital signs: 144/81 100% on
face mask respiratory rate 34 pulse of 133 temperature
96.5. Generally this is a white female in mild distress
appearing anxious. HEENT: Anicteric sclerae with clear dry
oropharynx. Pupils are equal round and reactive to light
and accommodation. Extraocular movements DISEASE are intact. Neck
is supple without lymphadenopathy DISEASE . Pulmonary: Decreased
breath sounds in the right base [**4-6**] of the way up with some
bronchial breath sounds egophony DISEASE and decreased tactile
fremitus. The left lung is clear to auscultation.
Cardiovascular: Tachycardia normal S1 S2. No murmurs or
thrills noted. Abdomen is soft nontender nondistended with
normoactive bowel sounds. Extremities: No clubbing DISEASE
cyanosis DISEASE or edema DISEASE noted. Neurological: Alert and oriented
times three and moving all four extremities.

LABORATORIES UPON ADMISSION: White count is 7.1 hematocrit
31.7 platelets 584. Sodium 136 potassium 4 chloride 98
bicarb 21 BUN 10 creatinine 0.4 glucose 144 calcium 9.1
magnesium 1.5 phosphate is 3.9. Bronchial brushing showed a
positive sample of nonsmall cell lung cancer DISEASE cells. Pleural
fluid on [**5-3**] show reactive mesothelial cells and no
malignant cells. On [**2145-4-5**] chest CT scan status post stent
showed stent in the right upper lobe bronchus marked with
narrowing of origin in the right middle bronchus moderate
pericardial effusion DISEASE small partial loculated right pleural
effusion right middle lobe opacity DISEASE and diffuse emphysema DISEASE .

A [**2145-5-21**] chest x-ray showed moderate large right pleural
effusion new consistent with compared with chest x-ray on
[**2145-5-7**].

HOSPITAL COURSE:
1. Pulmonary - Hemoptysis DISEASE : Patient was initially admitted to
the Intensive Care Unit to keep her saturation above 92%.
Her secretions and cough DISEASE were managed with Fentanyl and
saline nebulizer treatments. She did not have any episode of
hemoptysis DISEASE while in the Intensive Care Unit and actually
came down from her oxygen requirement from 100% nonrebreather
to sating 90% 4-5 liters. Her hematocrit remained stable.
She was called out to the floor where she was quite stable
until the second day on the medical floor where she then
experienced three tablespoons of hemoptysis DISEASE . She was then
transferred back to the Medical Intensive Care Unit for
observation. Her hematocrit remained stable and her
hemoptysis DISEASE decreased in frequency from seven episodes a day
to just five episodes a day with sputum production consistent
with a rust colored phlegm DISEASE . She had no frank hemoptysis DISEASE
while in the Medical Intensive Care Unit. She was then
called out to the medical floor where she soon had greater
than 150 cc hemoptysis DISEASE .

Cardiopulmonary resuscitation was aggressively attempted that
the patient could not be revived. Her airway could not be
managed with the blood that was aspirated during her episode
of hemoptysis DISEASE . The code was finally called off at 2 am on
[**2145-6-1**] with pronunciation of death DISEASE secondary to aspiration
from hemoptysis DISEASE .

In regards to her pulmonary effusion DISEASE it was thought that
there was no need for a thoracentesis at this time. If the
patient was to spike a fever DISEASE the Pulmonary team would
consider thoracentesis however she never did spike a fever DISEASE .

2. Infectious Disease DISEASE : The patient did have [**4-6**] blood
cultures on [**2145-5-26**] and sputum that grew out MSSA. She was
initially treated with Vancomycin 1 gram [**Hospital1 **] and continued on
Vancomycin given that she might develop sensitivities to
other types of antibiotics and the fact that she was
tolerating Vancomycin quite well. Given that her Vancomycin
trough was less than 10 her dosage was increased to 1250 mg
IV bid of the Vancomycin. A transesophageal echocardiogram
was never done because the patient requested that she have
some time to recover from her hemoptysis DISEASE .

3. Nonsmall cell lung cancer DISEASE : The patient was initially
going to be setup for phototherapy. However before this
could be attempted it was felt that her lung cancer DISEASE had
eroded into pulmonary arteries leading to the hemoptysis DISEASE
which eventually led to her death DISEASE .

DISCHARGE DIAGNOSES:
1. Death DISEASE secondary to aspiration from hemoptysis DISEASE from
nonsmall lung cancer DISEASE eroding to pulmonary arteries.
2. Methicillin sensitive Staphylococcus aureus bacteremia DISEASE .
3. Nonsmall cell lung cancer DISEASE .

DATE OF DEATH: [**2145-6-1**] at 2 am.




DR.[**Last Name (STitle) **][**First Name3 (LF) **] 12-AEW

Dictated By:[**Last Name (NamePattern1) 4270**]

MEDQUIST36

D: [**2145-6-1**] 14:00
T: [**2145-6-7**] 08:11
JOB#: [**Job Number 6263**]
Admission Date: [**2162-1-8**] Discharge Date: [**2162-1-13**]

Date of Birth: [**2106-7-20**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest burning DISEASE mild SOB

Major Surgical or Invasive Procedure:
[**2162-1-8**] Three Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary artery to left anterior descendingAdmission Date: [**2166-11-8**] Discharge Date: [**2166-11-12**]

Date of Birth: [**2091-11-12**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Keflex / Augmentin / Amoxicillin

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Respiratory Distress

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Pt is a 74 yo F with PMH of DM COPD and hx of foot osteo s/p
multiple debridements and surgeries admitted with respiratory
distress. The pt was found at home today in bed in respiratory
distress by her family. EMS was called and she was found to have
a O2 sat 60% and appeared to be cyanotic DISEASE . She was given sl NTG
and nebulizer and started on Bipap in the field. On arrival to
[**Hospital1 18**] ED Vitals T 102.2 HR 114 BP 156/60 RR 24 100% 40 FIO2. ECG
with sinus tachycardia DISEASE . CXR negative for evidence of PNA. She
was started on Vancomycin and Levofloxacin for fever DISEASE and was
given solu-medrol 125 X1.
.
On arrival to the MICU the patient was in no acute distress.
Answering questions appropriately. She denies shortness of breath or chest pain DISEASE . She was alert and oriented to place and
time. Her family reports that she has increased her tobacco
usage over the past week secondary to R hip pain DISEASE . She was found
by her husband and daughter to be gagging DISEASE with minimal
respiratory effort and appeared to have a blue-tinged color.


Past Medical History:
COPD/Asthma
Hypertension DISEASE
Diabetes Type II DISEASE
Peripheral neuropathy DISEASE
History of MRSA osteomyelitis right foot
MRSA bacteremia [**6-18**]
.
[**Doctor First Name **]: Bilateral cataracts DISEASE debridement of right foot
osteomyelitis DISEASE x3


Social History:
Lives with husband smokes 2 ppd x 50 years has recently been
under stress and admits to increasing her smoking to 3 ppd. Occ
ETOH lives in [**Location 686**].


Family History:
Noncontributory.

Physical Exam:
ADMISSION EXAM DISEASE :
VS: T:98.7 R:18 Sat:95% on Bipap 10/8 BP:162/59 HR:89
GEN: NAD well nourished
HEENT: PERRLA NCAT
Neck: no LAD
CV: s1/s2 no murmur pulses present
PULM: wheezes and rhonchi DISEASE throughout
ABD: soft NTND BS Admission Date: [**2169-8-16**] Discharge Date: [**2169-8-21**]

Date of Birth: [**2091-11-12**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Keflex / Augmentin / Amoxicillin

Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Tachycardia DISEASE

Major Surgical or Invasive Procedure:
Need for non-invasive ventilation and MICU stay.

History of Present Illness:
77F with h/o COPD DISEASE and recent admit mid-[**Month (only) **] for afib w/rvr
discharged on coumadin and diltiazem BIBA from home after VNA
noted her to be tachycardic and with labored breathing at home
this AM. Received dilt bolus by EMS and started on dilt gtt w/o
improvement in her heart rate. Pt had dementia DISEASE but had no
complaints. Endorsed chronic cough DISEASE . Denied cp or sob.

In the ED she was triggered for tachycardia DISEASE with HR 150 and
continued on a dilt gtt. HRs improved to the low 100s prior to
transfer to the floor. CXR showed mild pulm edema DISEASE with no
evidence of pneumonia DISEASE . She received IVF and
Ceftriaxone/Azithromycin. She was also noted to be febrile DISEASE to
102.8 UA was sent and blood and urine cultures were drawn and
Tylenol was given. Cr was noted to be 1.4 with lowest previous
value of 1.1. ABG performed at 1200 was 7.34/45/220. Family
noted patient to become increasingly somnolent around 1400.

On the floor the patient remained somnolent. Repeat ABG at 1700
was 7.24/60/68. Per family at bedside patient is alert and
awake at baseline. Given somnolence DISEASE and hypercarbia DISEASE and DNI
status the decision was made to transfer the patient to the
MICU. Prior to transfer she received 20mg IV furosemide with
minimal output and Foley was placed.

Review of systems: Unobtainable [**3-15**] patient's somnolence DISEASE .


Past Medical History:
-Hyperthyroidism dx [**7-/2169**]
-Atrial Fibrillation dx [**7-/2169**]
- Dementia DISEASE on aricept
- DM2 DISEASE A1C 6.6 in [**3-/2169**]
- COPD DISEASE not on O2 - Gait abnormality [**3-15**] MRSA osteomyelitis with 3 surgical
debridements
- HLD
- Diabetic nephropathy DISEASE
- Hypertension DISEASE
- s/p MRSA bacteremia in [**6-17**]
- bilateral cataract DISEASE surgery


Social History:
-Tobacco history: current smoking [**2-12**] ppd history of 60 years
at same amount (Admission Date: [**2145-9-7**] Discharge Date: [**2145-9-10**]

Date of Birth: [**2101-10-20**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain DISEASE

Major Surgical or Invasive Procedure:
Cardiac catheterization with one stent placed.


History of Present Illness:
43 y/o male with h/o HTN DISEASE who developed SSCP nonradiating
associated with arm/feet tingling around 12:30PM. He felt a
similar pain DISEASE 1 month ago after being involved in a fight and
being punched in the chest. No past history of DOE orthopnea DISEASE
or PND. The patient states that he was driving and developed
SSCP and he pulled over and called the ambulance. He was taken
to [**Hospital3 **] and his EKG revealed STE in anterolateral
leads. He was given ASA nitro gtt morphine heparin IV
lopressor 10 mg NS plavix 600 lipitor 80 and KCl 40. CXR
normal. He was transferred urgently to [**Hospital1 18**] for cath.
.
[**Hospital1 18**] cath revealed normal hemodynamics 99% LAD lesion DISEASE with
thrombus DISEASE s/p thrombectomy. No distal embolization. Normal flow.
.
The patient came to the CCU on nitro gtt. He still c/o CP with
no improvement after cath. No SOB or diapharesis.

Past Medical History:
PMH:
HTN DISEASE
.
PSH DISEASE :
None

Social History:
The patient is currently on parole for unclear reasons. He is
currently unemployed. He lives at home with his mom and sister.
[**Name (NI) **] admits to recent (Admission Date: [**2121-3-31**] Discharge Date: [**2121-4-4**]

Date of Birth: [**2054-10-31**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pain DISEASE

Major Surgical or Invasive Procedure:
[**2121-3-31**] - Coronary artery bypass grafting x3: Left internal
mammary artery to left anterior descending artery saphenous
vein graft to the diagonal saphenous vein graft to the
posterior descending artery.


History of Present Illness:
This 66 year old man has a history of hypertension DISEASE
hyperlipidemia DISEASE and obesity DISEASE . He has been followed in the [**Month/Day/Year 2200**]
clinic for quite some time. Over the summer the patient noticed
several episodes of bilateral shoulder discomfort while walking
up a slight incline on the golf course. These episodes would
resolve quickly with rest and then he would be able to continue
on with the rest of his game without symptoms.

Several weeks ago the patient noticed similar bilateral shoulder
discomfort after walking only 100 feet. He did not experience
any chest discomfort shortness of breath DISEASE or other associated
symptoms and again after several minutes of rest his discomfort
resolved.

He sought consultation with Dr. [**Last Name (STitle) 2201**] who referred him for
stress testing. He exercised 8.25 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol
reaching 79% of his maximum predicted heart rate. At peak
exercise there was diffuse 2.0-3.0 ST segment depression DISEASE in the
inferior leads and 1.0-2.0 mm depression DISEASE in leads I and V3-V6.
The rhythm was sinus with APBAdmission Date: [**2193-8-29**] Discharge Date: [**2193-9-16**]

Date of Birth: [**2156-6-6**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Leg and back pain DISEASE

Major Surgical or Invasive Procedure:
1. Left L4-L5 Microdiscectomy
2. Exploratory laparotomy with primary repair of inferior vena
cava injury DISEASE and Dacron interposition graft repair of right
common iliac artery transection.
3. Primary abdominal wall closure with placement of retention
sutures and Ethicon wound bridges.


History of Present Illness:
(Per medical record)
Ms. [**Known lastname **] has had low back pain DISEASE for the past several months that
has been stable. However in [**Month (only) 216**] she developed acute onset of
severe pain DISEASE in her L leg from the buttock region down the leg
and all the way to the end of her foot. There is also a sense of
numbness DISEASE . She tried epidural steroid injections without much
relief.

Past Medical History:
Gastroparesis DISEASE
Psoriasis DISEASE
Anxiety DISEASE

Social History:
Married. She works as a lawyer and has to travel for work.

Family History:
Noncontributory

Physical Exam:
On pre-op exam:

General: pleasant appears uncomfortable with walking though
can
walk from exam room to waiting room and bathroomAdmission Date: [**2137-12-10**] Discharge Date: [**2137-12-17**]

Date of Birth: [**2077-8-2**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Iodine-131 / Epinephrine

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea DISEASE on Exertion

Major Surgical or Invasive Procedure:
Minimally Invasive Mitral Valve Repair with 30mm [**Doctor Last Name 405**] Band
on [**2137-12-10**]

History of Present Illness:
60 y/o female with h/o mitral vlave prolapse for 40 yrs. Has had
increased dyspnea DISEASE on exertion this year with an episode of
congestive heart failure DISEASE [**9-16**]. Recent echo showed 4Admission Date: [**2182-3-26**] Discharge Date: [**2182-3-29**]

Date of Birth: [**2118-9-5**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Shortness of breath / n / v / diarrhea DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
63M with history of asthma DISEASE possible ILD DM DISEASE presenting from
home with shortness of breath DISEASE . He has been troubled by flares DISEASE of
shortness of breath cough DISEASE and feeling of phlegm DISEASE in his chest
for 9 months. Episodes at times also associated with feeling
feverish without documented elevated temps and sweats. In PCP's
office also noted to have hypertension DISEASE and tachycardia DISEASE . Had
cardiac stress testing trhough PCP which was normal. These
episodes generally last two to three days and go away with
increasing prednisone. He has been off and on prednisone
throughout these months (up to 30-40 mg daily). One month ago
was on 5 mg but has been gradually increasing steadily up to 25
mg two days ago. Today took 15 mg. He was able to exercise
yesterday walking 30 minutes on the treadmill. Last night
developed repeated episodes of diarrhea DISEASE as well as nausea DISEASE and
malaise. Breahting seemed to be worse this AM so went to ED. No
abdominal or chest pain DISEASE . Endorses orthopnea DISEASE and worsening of
chest congestions/phlegm feeling when supine. Has pitting edema DISEASE
which comes and goes he notes improving with exercise. Has not
noted significant change in sugars at home. No sick contacts.
Did receive both flu vaccines this year.
.
In the ED initial vs were: T98.3 133 143/85 28 99% on NRBAdmission Date: [**2117-11-7**] Discharge Date: [**2117-11-20**]

Date of Birth: [**2065-2-7**] Sex: F

Service: NEUROLOGY

Allergies DISEASE :
Aspirin

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left leg weakness DISEASE


Major Surgical or Invasive Procedure:
Spinal Tap.
Cerebral Angiogram x 2.


History of Present Illness:
52yo RH F h/o smoking until recently and multiple recent ED
visits for headache DISEASE (LP negative for meningitis SAH DISEASE ) and seen
in neurology clinic with normal motor exam as recently as [**11-4**]
by Dr. [**First Name (STitle) 6817**] who prescribed fioricet for combination
migraine/tension headache DISEASE . She began taking it on Friday two
days ago and per her husband she was too drowsy and
disinhibited. He has not given it to her since. Her behavior has
remained odd since then and her family present at my interview
says she has been overly jovial for the past few days.

Her headache DISEASE though has ceased apart from a Admission Date: [**2187-2-22**] Discharge Date: [**2187-2-28**]


Service: MEDICINE

Allergies DISEASE :
Vicodin / Penicillins / Compazine

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Altered mental status.

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
[**Age over 90 **] year-old female who presents from a rehabilitation facility
after one week of altered mental status. At baseline the patient
has been alert but confused and agitated worse at nightAdmission Date: [**2148-5-28**] Discharge Date: [**2148-6-3**]

Date of Birth: [**2071-7-22**] Sex: M

Service: Neurosurgery

HISTORY OF PRESENT ILLNESS: This is a right-handed
77-year-old Chinese-speaking man with dementia DISEASE who presents
with left lower extremity weakness two days after unwitnessed DISEASE
fall at home. The patient fell on Saturday afternoon. As he
is normally home alone all day no one saw him and the wife
found him on the floor with his head on the recliner when she
arrived home in the afternoon. The patient aroused easily
and was in his usual state of health until Sunday when he had
sudden profound weakness of the left lower extremity DISEASE while
walking. The wife stated that she Admission Date: [**2148-5-28**] Discharge Date: [**2148-6-3**]

Date of Birth: [**2071-7-22**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 77 year old
Chinese speaking male who presented to the [**Hospital1 346**] Emergency Department with left lower
extremity weakness. The weakness DISEASE occurred following a fall
two days prior. The patient is a right handed Chinese
speaking male with baseline dementia DISEASE . On presentation he
had left lower extremity weakness DISEASE following the unwitnessed DISEASE
fall at home. By patient's family report he fell on
Saturday afternoon having been home alone all day and was
found later that afternoon by his wife. She managed to
arouse him and move him to a recliner but no further action
was taken. Following the fall the patient was in his usual
state of health until the following evening on Sunday when
by family's report had had a sudden and profound weakness of
the left lower extremity while walking. The wife is said to
have carried the patient back to his bed and the EMS was
activated.

On presentation to the Emergency Department the patient was
lethargic with confusion DISEASE beyond his normal baseline dementia DISEASE .
Through a translator he is oriented to place and recognizes
face although he can be difficult to arouse at times.

By family report there was no noticeable change in visual or
speech patterns and the patient appears to comprehend them.
They do however report that he has had difficulty moving
food to his face.

MEDICATIONS: The patient presented to the Emergency
Department on no chronic medications.

PHYSICAL EXAMINATION: On presentation to the Emergency
Department vital signs are a blood pressure of 153/78Admission Date: [**2149-12-10**] Discharge Date: [**2149-12-15**]

Date of Birth: [**2071-7-22**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
right sided weakness

Major Surgical or Invasive Procedure:
CTs
Swallow evaluation

History of Present Illness:
This is a 78 yo Cantonese speaking right handed man with a
history of vascular dementia stroke DISEASE with left sided weakness
HTN DISEASE h/o right SDH s/p evacuation who was in his usual state of
health until this morning. He walked to the bathroom and did
not come out for 20 minutes. His wife got worried and walked in
to find him curled up on the bathroom floor. He saidAdmission Date: [**2108-3-11**] Discharge Date: [**2108-3-12**]

Date of Birth: [**2039-6-15**] Sex: M

Service: MICU


CHIEF COMPLAINT: Dyspnea acute renal failure.

HISTORY OF PRESENT ILLNESS: A 68-year-old ophthalmologist
with no significant past medical history who presents today
with diffuse muscle pain DISEASE and dyspnea DISEASE on exertion times six
days. Symptoms started when patient awoke six days prior to
admission with lumbar lower back pain. Patient states that
initially the pain DISEASE was similar to lumbar back pain DISEASE in the
past however he usually notices this type of pain DISEASE at the
end of the day rather than first thing in the morning.
Throughout the day his lower back pain DISEASE worsened and patient
began to note diffuse myalgias DISEASE . Upon getting home from work
that evening he reports that the pain DISEASE and myalgias DISEASE were so
severe that he was unable to walk. The weakness DISEASE has worsened
throughout the course of the week and patient has been
nonambulatory.

His dyspnea DISEASE on exertion began around the same time as the
muscle weakness DISEASE and prior to being unable to walk he was
only able to do three steps before he became tachypneic. He
does not report any PND or orthopnea DISEASE .

The patient has also recently traveled to [**State 108**]
approximately 10 days ago. While he was in [**State 108**] he had
an acute diarrheal illness DISEASE which was described as watery DISEASE and
nonbloody. This resolved spontaneously and was self limited.
He was unclear if this was associated with fevers DISEASE .

Five days prior to admission he again had recurrence of
symptoms and his diarrhea DISEASE in addition to above symptoms of
myalgias DISEASE and weakness DISEASE . His original episode of diarrhea DISEASE was
thought to be secondary to eating out at a restaurant with
Cuban cuisine and possible beef exposure. He does not
believe he had any fresh water exposure and he was not
swimming in any pools.

On presentation to the Emergency Department he was noted to
be in moderate respiratory distress DISEASE with respiratory rates in
the 30s and tachycardic with heart rates in the 100s. He was
placed on nonrebreather face mask with initial oxygen
saturation 88 percent which improved to 95 percent on 3
liters without any intervention. Initial ABG showed
7.33/21/134 on unknown amount of oxygen. He received 2
liters of intravenous normal saline while in the Emergency
Department and had development of bibasilar rales DISEASE . He did
not have any change in his oxygen saturation while lying
supine.

On review of systems patient complains of mild oliguria DISEASE
which he reports usually going 10 times per day which
decreased to one time per day over the last six days. He
noted brown urine starting approximately four days ago. He
has not had any dysuria DISEASE or hematuria DISEASE as far as he knows. He
also reports a sore throat with a question of dysarthria DISEASE at
the onset of symptoms five to six days ago. He has had a
headache DISEASE and some blurry vision. The blurry vision was
approximately two days prior to admission and lasted about 24
hours. One day prior to admission he believes he also had an
episode of diplopia DISEASE which lasted approximately six hours.
He has not had any abdominal pain nausea vomiting DISEASE chest
pain DISEASE or palpitations DISEASE . Of note he and his wife who is also
a physician noted that his thighs were mottled.

PAST MEDICAL HISTORY:
1. GERD.
2. Raynaud DISEASE 's phenomenon.
3. Adenomatous polyps DISEASE x2 resected per colonoscopy in [**2105**].
4. Osteopenia DISEASE .
5. Status post inguinal hernia DISEASE repair.
6. Hyperlipidemia DISEASE .
7. History of lower back pain DISEASE .


MEDICATIONS AT HOME:
1. Aspirin 81 q.d.
2. Lipitor 20 mg q.d. which has been a stable dose over the
last six to seven years.
3. Prilosec 20 q.d.
4. Aleve two tablets q.d. prn however patient has been
taking approximately four tablets per day since the onset
of symptoms six days ago.
5. Feldene 20 mg p.o. q.d.


ALLERGIES:
1. Mice dander causes anaphylactic reaction DISEASE .
2. Mussels (seafood) causes GI upset however other
shellfish are okay.


FAMILY MEDICAL HISTORY: Mother with [**Name (NI) 2481**]. Father
died at age 89 years old of prostate cancer DISEASE .

SOCIAL HISTORY: Patient is an ophthalmologist/researcher in
the area. He is married. His wife is also a physician. [**Name10 (NameIs) **]
denies any tobacco use. He drinks approximately one glass of
wine per day. He has three children most of whom live in
the area.

Vital signs in the Emergency Department: Temperature 94.6
blood pressure 129/90 which increased to 145/75 after 2
liters of intravenous fluid heart rate went from 105 to 95
respiratory rate 20s oxygen saturation 89 percentile on
rebreather face mask which improved to 95 percent on 3
liters nasal cannula.

In general patient was in mild respiratory distress DISEASE
however he was able to speak in full sentences. There was
no accessory muscle use. HEENT exam: Pupils are equal
round and reactive. Sclerae were anicteric. Extraocular
muscles are intact. Mucous membranes were moist. His
oropharynx was clear. He was normocephalic atraumatic.
Neck was supple without any jugular venous distention or
thyromegaly. Chest demonstrated bilateral basilar rales DISEASE
without any wheezes. Cardiovascular: Regular rate no
murmurs rubs or gallops were appreciated. Abdomen was
soft nontender nondistended liver span percussed to
approximately 3-4 cm above costal margin. There was no
splenomegaly DISEASE . There is a negative [**Doctor Last Name 515**] sign. On back
exam he had no midline spinal tenderness to palpation. He
had no CVA tenderness bilaterally. Extremities demonstrated
two plus peripheral pulses. There is trace bilateral edema DISEASE .
Skin exam: He had no rashes however there is evidence of
livido reticularis on bilateral thighs. On neurologic exam
he was alert and oriented times four with cranial nerves II
through XII intact. Deep tendon reflexes were symmetric.
Motor strength was effort dependent however he had 3-4/5
weakness DISEASE in his bilateral hip flexors knee extensors knee
flexion with intact strength bilateral plantar flexion
dorsiflexion. His upper extremities were 4 plus bilaterally.
He had a negative Babinski DISEASE . His sensation was intact to
light touch bilateral upper and lower extremities.

LABORATORY VALUES ON PRESENTATION: White blood cells 6.5
hemoglobin 15.5 hematocrit 46.6 MCV 91 67 percent
neutrophils 11 percent bands 8 percent lymphocytes 9
percent monocytes. PT 14.7 PTT 29.8 INR of 1.4.
Urinalysis showed large blood nitrite positive 100 protein
trace ketones negative for leukocytes negative for RBCs
negative WBCs few bacteria. Sodium was 140 potassium 3.5
chloride 97 bicarb 13 BUN 72 creatinine 4.0 which is up
from a baseline of 1.0 glucose 200 anion gap was elevated
at 30. ALT was 96 AST 164 CK 1654 alkaline phosphatase
310 total bilirubin 5.2 direct bilirubin 3.8. Lipase was
20. Troponin was less than 0.01. Calcium 9.8 phosphorus
3.3 magnesium 2.8 albumin 3.3. Serum and urine tox were
both negative.

DIAGNOSTIC IMAGING:
1. Chest x-ray showed linear atelectasis DISEASE at the left base
with a right lower lobe nodule.
2. CT head was negative for acute pathology.
3. Abdominal ultrasound showed normal liver portal vein
patent right kidney 11.7 cm with 1.7 cm simple cyst left kidney DISEASE was 10.8 cm. No hydronephrosis DISEASE and no ascites DISEASE were
present.
4. EKG showed a sinus tachycardia DISEASE rate 112 P-R of 150
normal axis T-wave inversions in III and F unchanged
when compared with EKG dated [**2104-5-29**].


IMPRESSION: A 68-year-old gentleman with no significant past
medical history who presents with six days of lower back
pain myalgias DISEASE with remote history of diarrheal illness DISEASE and
possible fevers DISEASE at home. While in the Emergency Department
identified to have mild respiratory distress DISEASE which improved
without significant intervention as well as acute renal failure DISEASE and elevated CK. Also noted to be hypothermic with a
left shift.

HOSPITAL COURSE: Patient was admitted to the Medical
Intensive Care Unit given his acute renal failure DISEASE and
respiratory distress DISEASE . He arrived in the Medical Intensive
Care Unit approximately 6 p.m. and he was noted to have cold
and clammy extremities DISEASE and was now on 6 liters of oxygen per
nasal cannula. Over the next two hours the patient
exhibited worsening tachypnea DISEASE and altered mental status. He
was noted to have worsening slurring of his speech DISEASE as well.

Neurology evaluated the patient approximately one hour after
being admitted to the Intensive Care Unit and although was
not able to provide a coherent history at that point
provided a good exam which was felt to be nonfocal except
for mild tongue weakness DISEASE .

Around 8 p.m. patient's condition had deteriorated enough
that he was extremely delirious DISEASE and his respiratory rate had
increased to approximately 40 and he was taking short and
shallow breaths. He was intubated at that point without any
complications.

After intubation an arterial blood gas was performed which
showed a pH of 7.14 pCO2 of 36 and a lactate of 8.0. Given
his worsening clinical condition he was started on empiric
antibiotics at that point for presumed blood-born infection DISEASE .
Initial antibiotics were broad spectrum and included Zosyn
Levaquin doxycycline Vancomycin Flagyl.

After intubation a left subclavian line was attempted
however was unsuccessful. A left internal jugular central
venous catheter was placed without complications. Followup
chest x-ray after central line placement showed a moderate
sized pneumothorax DISEASE on the left which was decompressed with a
chest tube placed by Cardiothoracic Surgery.

Around midnight that evening approximately six hours after
admission to the Intensive Care Unit patient's blood
pressure had progressively fallen and now required
intravenous pressors. He was initially started on Levophed
and eventually Vasopressin followed by Neo-Synephrine were
added. Laboratory values returned with values consistent
with DIC.

Likewise his respiratory status declined throughout the
evening and cisastracurium was used for paralysis DISEASE . ARDS Net
ventilation strategy was employed however he was very
difficult to oxygenate throughout the evening. Serial blood
gases showed progressive worsening of his acidosis DISEASE and by 10
a.m. the next morning 16 hours after admission his blood
gas showed a pH of 6.92 and a lactate of 11.8. He had been
previously on a bicarb drip throughout the evening with no
apparent effect.

His potassium continued to rise throughout a few short hours
in the Intensive Care Unit and reached a level of 9.1 the
following morning at 11 a.m. The Nephrology team which had
been following him from the night before given his acute
renal failure DISEASE were contact[**Name (NI) **] early in the morning and a CVVH
was initiated. Around the time of initiation of CVVH
patient was noted to have a wide complex tachycardia and was
eventually found to have evidence of complete heart block DISEASE .
Blood pressures despite maximum dose of three vasopressive
medications remained with the systolics in the 80s to 90s and
heart rate in the 50s to 60s.

A discussion was had with his wife who felt that
resuscitation would not be consistent with patient's wishes
and he expired at 2:30 p.m. secondary to cardiac arrest DISEASE .

Blood cultures drawn from time of admission in the Emergency
Department later grew out methicillin-sensitive Staph aureus
in four blood culture bottles. Further investigation and
discussion with wife revealed that patient had a dental
procedure approximately three weeks prior to admission. It
is unclear this was the source of his bacteremia DISEASE or whether
there was some infectious process which was acquired while
he was on [**State 108**] a week and a half prior to admission.

After discussion with his wife an autopsy was performed
(which report is not available at this time) which was
consistent with septic DISEASE emboli to multiple organs including
his kidneys. This was the most likely cause of his acute
renal failure DISEASE . There is also evidence of mitral valve
involvement/endocarditis.

DIAGNOSIS AT TIME OF DEATH:
1. Methicillin-sensitive Staphylococcus aureus high grade
bacteremia DISEASE .
2. Endocarditis DISEASE .
3. Septic DISEASE embolic involvement of bilateral kidneys.
4. DIC.
5. Acute respiratory distress syndrome DISEASE .
6. Metabolic acidosis DISEASE .
7. Hyperkalemia DISEASE secondary to acute renal failure DISEASE .
8. Myositis DISEASE .
9. Respiratory failure DISEASE requiring intubation.
10. Left tension pneumothorax DISEASE .




DR.[**Last Name (STitle) **][**First Name3 (LF) **] 12-697

Dictated By:[**Last Name (NamePattern1) 6829**]
MEDQUIST36
D: [**2108-5-9**] 15:16:34
T: [**2108-5-10**] 09:00:23
Job#: [**Job Number 6830**]




Admission Date: [**2112-1-18**] Discharge Date: [**2112-1-30**]

Date of Birth: Sex:

Service: [**Doctor Last Name 1181**]

HISTORY OF PRESENT ILLNESS: This is an 86 year-old woman
from [**Hospital3 **] Center where she was found
minimally responsive cyanotic DISEASE diaphoretic and tachypneic DISEASE
with an O2 sat between 34 and 54% on 6 liter per minute
oxygen mask. She was brought to the Emergency Department
where she was initially verbal and complained of some upper
back pain DISEASE and some shortness of breath DISEASE . Her vital signs in
the Emergency Department were a blood pressure of 162/77
heart rate 70 respirations 40 and her O2 sat was 93% on a
nonrebreather mask. It was 100% on norebreather mask. She
was initially given 40 mg of intravenous Lasix times one in
the Emergency Department but then became hypotensive DISEASE with a
blood pressure of 79/47. She required a Dopamine drip. The
Dopamine was weaned off and then restarted later as the blood
pressure fell yet again. Dopamine was later stopped and a
neo drip was started which was later weaned off.

The patient was admitted to the [**Doctor Last Name **] firm on the [**2112-1-18**]. She was treated with Levofloxacin and Flagyl
for a urinary tract infection DISEASE as well as possible aspiration
pneumonia DISEASE . She had a swallow study on the [**2112-1-19**] which she described as a borderline dysphagia DISEASE and was
made NPO but later the patient was inadvertently fed ice
cream by a patient. The patient was later found to have a
drop in O2 sats down to 70% and required intubation transfer
to the Medical Intensive Care Unit. Suctioning at that time
was positive for melted ice cream. The patient was extubated
on the [**1-21**] but then felt distressed believed to
be mechanical restrictive lung disease DISEASE . The patient has
noted kyphosis scoliosis as well as congestive heart failure DISEASE
and pneumonia DISEASE and required BiPAP at night and face mask
during the day. On the [**1-27**] the patient's nephew
decided to change the patient's status to DNR/DNI and comfort
measures only and the patient was transferred back to the
[**Doctor Last Name **] firm on the [**2112-1-28**].

PAST MEDICAL HISTORY: Congestive heart failure acute renal
failure atrial fibrillation DISEASE coronary artery disease DISEASE
hypertension DISEASE and a history of scoliosis DISEASE and kyphosis DISEASE .

ALLERGIES: Intolerant of ace inhibitors.

MEDICATIONS ON TRANSFER:
1. Metoprolol 25 b.i.d.
2. Losartan 75 mg daily.
3. Multivitamin.
4. Admission Date: [**2147-11-17**] Discharge Date: [**2147-12-5**]

Date of Birth: [**2092-11-28**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1**]
Chief Complaint:
headache DISEASE and neck stiffness DISEASE

Major Surgical or Invasive Procedure:
central line placed arterial line placed

History of Present Illness:
54 year old female with recent diagnosis of ulcerative colitis DISEASE
on 6-mercaptopurine prednisone 40-60 mg daily who presents
with a new onset of headache DISEASE and neck stiffness DISEASE . The patient is
in distress rigoring and has aphasia DISEASE and only limited history
is obtained. She reports that she was awaken 1AM the morning of
[**2147-11-16**] with a headache DISEASE which she describes as bandlike. She
states that headaches DISEASE are unusual for her. She denies photo- or
phonophobia DISEASE . She did have neck stiffness DISEASE . On arrival to the ED
at 5:33PM she was afebrile with a temp of 96.5 DISEASE however she
later spiked with temp to 104.4 (rectal) HR 91 BP 112/54 RR
24 O2 sat 100 %. Head CT was done and relealved attenuation
within the subcortical white matter of the right medial frontal
lobe. LP was performed showing opening pressure 24 cm H2O WBC of
316 Protein 152 glucose 16. She was given Vancomycin 1 gm IV
Ceftriaxone 2 gm IV Acyclovir 800 mg IV Ambesone 183 IV
Ampicillin 2 gm IV q 4 Morphine 2-4 mg Q 4-6 Tylenol 1 gm
Decadron 10 mg IV. The patient was evaluated by Neuro in the
ED.
.
Of note the patient was recently diagnosed with UC DISEASE and was
started on 6MP and a prednisone taper along with steroid enemas
for UC DISEASE treatment. She was on Bactrim in past but stopped taking
it for unclear reasons and unclear how long ago.
.


Past Medical History:
chronic back pain DISEASE MRI negative
osteopenia DISEASE - fosamax d/c by PcP DISEASE
leg pain/parasthesias
h/o hiatal hernia DISEASE

Social History:
No tob Etoh. Patient lives alone in a 2 family home w/ a
friend. She is an administrative assistant


Family History:
brother w/ ulcerative proctitis DISEASE mother w/ severe arthritis DISEASE
father w/ h/o colon polyps DISEASE and GERD DISEASE

Physical Exam:
VS: 101.4 Admission Date: [**2176-4-22**] Discharge Date: [**2176-4-27**]

Date of Birth: [**2118-8-24**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Shellfish Derived

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea DISEASE on exertion


Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 3 (LIMA-LAD SVG-OM SVG-LPDA) [**2176-4-22**]


History of Present Illness:
57 year old male has a history of hypertension hyperlipidemia DISEASE
and insulin dependent diabetes DISEASE . He has been fairly sedentary
over the past year and recently began to notice that he was
having dyspnea DISEASE with activities that he previously could do
without problems including climbing a flight of stairs or
walking up a slight incline. At times this has been associated
with mild left sided chest discomfort. Recent stress echo
revealed ischemia DISEASE c/w three vessel disease DISEASE or LM disease DISEASE . He was
referred for cardiac catheterization to further evaluate. He was
found to have multivessel disease DISEASE and is now being referred to
cardiac surgery for revascularization.


Past Medical History:
Coronary Artery Disease DISEASE
s/p Coronary artery Bypass x 3
PMH:
Hypertension DISEASE
Hyperlipidemia DISEASE
Insulin dependent diabetes DISEASE
Hx of bladder cancer DISEASE s/p laser surgery/cauterization
s/p Cholecystectomy
Umbilical hernia DISEASE
Common bile duct stone DISEASE s/p ERCP with sphincterotomy [**2175-3-20**]


Social History:
Lives with:Wife
Occupation:consultant for school systems
Tobacco:quit 27 years ago
ETOH: 1 drink per week


Family History:
Father had a stroke DISEASE while having a cardiac
catheterization and CABG


Physical Exam:
Pulse:51 Resp:16 O2 sat: 99/Ra
B/P Right:162/77 Left:158/66
Height:5'6Admission Date: [**2169-3-29**] Discharge Date: [**2169-3-31**]


Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
infected left AV DISEASE graft

Major Surgical or Invasive Procedure:
excision of infected left AV graft [**2169-3-29**] DISEASE


History of Present Illness:
89 yo male who presented with chills DISEASE at dialysis. He was noted
to have a fever DISEASE to 102 at that time. While at dialysis he was
noted to have a ulceration over his left AV graft site with
bleeding DISEASE . He was transferred to [**Hospital1 18**] for further evaluation
and work-up of a likely infected left AV DISEASE graft.

Past Medical History:
CKD-- stage IV disease baseline Admission Date: [**2126-3-11**] Discharge Date: [**2126-3-18**]

Date of Birth: [**2077-3-10**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
Cardiac catheterization
Internal cardiac defibrillator placement


History of Present Illness:
This is a 49 year-old male with a history of HBV hepatitis DISEASE on
entecavir hypercholesterolemia family history of premature
CAD who presents with leg swelling DISEASE and progressive SOB.
.
Worked up in late [**2125-12-10**] for week or so of cough DISEASE told he
had pneumonia DISEASE by CXR received 5 days of azyhtromycin w/o any
improvement in his cough DISEASE . Got second CXR around [**12-24**]
findings had not cleared got another course of 5 days
Azithromycin which he finished 7 days prior to presentation
again w/o improvement in cough DISEASE . During this period except for
cough DISEASE complained of exertional dyspnea DISEASE which has progressed
rapidly over the past week from 20 stairs to dyspnea DISEASE at rest.
Admits to orthopnea DISEASE two or more pillows describes paroxysmal
cough DISEASE at night but not PND. Noticed 11 lb weight gain DISEASE over past
two months. No nocturia DISEASE . Denies chest pain DISEASE . Two days prior to
admission had CT chest which showed diffuse bilateral
ground-glass infiltrates DISEASE consistent with infectious DISEASE process
most likely atypical or viral pneumonia DISEASE as well as bilateral
pleural effusions DISEASE . On day prior to admission noticed swelling DISEASE
on right foot followed later by left foot swelling. Saw his PCP
who sent him to the ER.
.
Does not recall recent febrile illness DISEASE . Believes all his
symptoms started after Admission Date: [**2167-4-11**] Discharge Date: [**2167-4-19**]

Date of Birth: [**2124-2-10**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Compazine

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Leg cramps

Major Surgical or Invasive Procedure:
Lumbar puncture


History of Present Illness:
43 yo M with history of rhabdomyolysis DISEASE related to mitochondrial
d/o comes w/ cramping DISEASE in legs. Pt reports he's been feeling
somewhat unwell since 2 days ago when he nausea DISEASE after eating
chicken panini from [**Company **]. However his symptom resolved
by the end of the day. No diarrhea/abdominal pain/fevers or
chills DISEASE . Yesterday he was moving boxes because he's moving to a
different apt and felt tired and took a nap. After taking a nap
he woke up with calf muscle cramping DISEASE and checked urine myoglobin
at home which was positive. He then came to the ED. Otherwise
he denies any chest pain DISEASE sob cough diarrhea abdominal pain DISEASE
or constipation DISEASE . He reports some HA and nasal congestion DISEASE but no
vision changes stiff neck neck pain DISEASE or rhinorrhea DISEASE .
.
In the Emergency Department his CK was noted to be in 50000s
and received 1L NS. 1L of bicarb was started. Initially for
close monitor of urine output hourly and 'lytes in the setting
of aggressive IVF there was a consideration for MICU admission.
However MICU attending did not feel that he warranted MICU
admission thus floor admission was decided. However from the
[**Name (NI) **] pt went to MICU. Upon arrival to MICU pt's VS was 98.3
144/90 102 11 99% on RA DISEASE . Upon hearing that pt's moving again
to CC7 again pt became upset and tachycardic to 120-130s and
hypertensive DISEASE to 182/105. Currently pt's BP 144/98 HR 94 16
sat 98% on RA DISEASE . Pt had uop of 500cc of tea-colored DISEASE urine while in
MICU. While in MICU pt finished 1L bicarb and received 2 L of
NS. 4th NS is running currently. Pt is refusing foley.


Past Medical History:
1. Mitochondrial myopathy DISEASE with recurrent rhabdomyolysisAdmission Date: [**2104-8-21**] Discharge Date: [**2104-8-26**]


Service: MEDICAL

HISTORY OF PRESENT ILLNESS: This is a 78 year old woman with
a history of severe chronic obstructive pulmonary disease DISEASE
ulcerative colitis DISEASE status post ileostomy in [**2097**] aortic
stenosis status post valvuloplasty in [**2097**] and then aortic
valve replacement with a porcine aortic valve in [**2098**] and a
left below the knee amputation in [**2065**] who has had one week
of cough DISEASE and sputum production that was treated with Levaquin
and Flagyl.

Two days prior to admission the patient developed nausea DISEASE and
vomiting DISEASE and stopped taking her Flagyl DISEASE but still had nausea DISEASE .
She stopped being able to eat well and had some respiratory
distress and had diarrhea DISEASE . She was sent to the Emergency
Department for evaluation. She denied any chest pain DISEASE denied
any blood in the diarrhea DISEASE denied any blood in her vomit DISEASE
denied fever chills DISEASE .

PHYSICAL EXAMINATION: On arrival in the Emergency
Department the patient's examination revealed she was an
uncomfortable dyspneic woman on oxygen via nasal cannula who
had to pause while speaking secondary to her dyspnea DISEASE . She
was afebrile. Her blood pressure was 116/60 with a pulse of
86 respiratory rate 20s with oxygen saturation of 95% in
room air. Head eyes ears nose and throat - She was
normocephalic and atraumatic with no icterus DISEASE . Her mucous
membranes were dry DISEASE . She had no jugular venous distention DISEASE .
Her chest had basilar crackles bilaterally diffusely
decreased breath sounds. The heart was regular. She had a
III/VI midsystolic murmur DISEASE . Her abdomen was obese soft
nontender no hepatosplenomegaly DISEASE . The ileostomy bag was in
place. Her extremities revealed status post left below the
knee amputation. Her right lower extremity was cool with
chronic erythema DISEASE and venous stasis DISEASE changes and trace edema.

LABORATORY DATA: On admission white count 13.9 hematocrit
42.5 platelets 308000. INR 2.1. Chem7 revealed a sodium of
136 potassium 5.7 chloride 111 bicarbonate 6 blood urea
nitrogen 120 creatinine 3.0 glucose 110. A troponin was
less than 0.3. Urinalysis had 30 protein specific gravity
of 1.016 three white cells two red cells and a few
bacteria. ALT was 8 AST 20 alkaline phosphatase 102 total
bilirubin 0.4 amylase 111 CK 53.

Her chest x-ray showed no congestive heart failure DISEASE and no
pneumonia DISEASE . Arterial blood gases at that time revealed pH
7.21 pCO2 22 pO2 153.

Electrocardiogram showed sinus rhythm at 90 beats per minute.
Q wave in III aVF and V2 1.[**Street Address(2) 2811**] depressions DISEASE in
II V3 through V6. T wave inversions in I II aVL V4
through V6 and biphasic in V3.

HOSPITAL COURSE: She was admitted to the Medical Intensive
Care Unit for correction of her metabolic acidosis DISEASE and acute
renal failure DISEASE and for ruling out acute myocardial infarction DISEASE .

1. Metabolic acidosis DISEASE - She was given three amps of
bicarbonate in one liter of fluid. She had blood cultures
drawn. She was treated with oxygen. Calcium phosphorus and
magnesium levels were drawn and found to be low. She was
repleted with those intravenously and her acidosis DISEASE responded
so that on the day of transfer to the floor her bicarbonate
was 19 and she was able to tolerate p.o.

2. Acute renal failure DISEASE - She had a creatinine of 3.0 when
her baseline is 1.1. This responded well to intravenous
fluid hydration so that on the day of transfer to the floor
her creatinine was 1.8 and on the day of discharge from the
hospital her creatinine was 1.3.

It was thought that both metabolic acidosis DISEASE and the acute
renal failure DISEASE were secondary to severe volume depletion from
diarrhea DISEASE and decreased p.o. intake. She has responded well
to intravenous rehydration and repletion of her electrolytes.

3. Rule out myocardial infarction DISEASE - Serial CKs were done
which were negative. Her troponin was always less than 0.3.
Despite the changes on the electrocardiogram she was found
not to have had a myocardial infarction DISEASE . It was thought that
these changes were secondary to some ischemia DISEASE probably
induced by the volume depletion.

4. Respiratory - She began to have some increasing shortness DISEASE
of breath on the day of transfer to the floor and stated that
at home she takes Albuterol nebulizer twice a day. These
were started on the floor and her breathing improved. She
continued on her normal respiratory medications inhalers and
was continued on b.i.d. nebulizers.

5. Gastrointestinal - The patient presented with nausea DISEASE
vomiting diarrhea DISEASE and decreased p.o. intake. Over her
hospital stay the diarrhea DISEASE decreased and her stools became
more formed. She was able to tolerate p.o. and hydrate
herself and replete her electrolytes through p.o. Amylase and
lipase were within normal limits throughout her hospital
stay.

6. Infectious disease - The patient was diagnosed with
pneumonia DISEASE prior to admission and stopped her antibiotics
during her illness. No consolidation was seen on chest x-ray
but it was decided to treat her with Levaquin and Flagyl.
Flagyl was discontinued two days prior to discharge and she
will be continued on Levaquin for a total of ten days and
will stop her course on [**2104-9-1**]. Her blood cultures have
been negative throughout as has a urine culture and she has
been afebrile since her transfer from the Medical Intensive
Care Unit.

7. Hematology - Her INR was 2.1 on admission and it was
subsequently checked and found to be 1.9. Her liver function
tests were normal and it was felt that this was due to
Vitamin K depletion from poor nutrition. She was given
Vitamin K p.o. for three days and her INR will be checked
again as an outpatient.

She will follow-up with her regular primary care physician
when she gets home.

CONDITION ON DISCHARGE: Stable.

DISCHARGE STATUS: She will be discharged to a rehabilitation
facility for further assistance with her activities of daily
living respiratory status and her p.o. repletion.

MEDICATIONS ON DISCHARGE:
1. Albuterol and Atrovent nebulizers b.i.d.
2. Atrovent MDI two puffs b.i.d.
3. Vanceril MDI four puffs b.i.d.
4. Humibid 600 mg p.o. b.i.d.
5. Zantac 150 mg p.o. q.d.
6. Isordil 10 mg p.o. t.i.d.
7. Metoprolol 25 mg p.o. b.i.d.
8. Levofloxacin 250 mg p.o. q.d. to finish on [**2104-9-1**].
9. Heparin 5000 units subcutaneous q.d.
10. Magnesium Oxide 420 mg p.o. t.i.d.
11. Elavil 10 mg p.o. q.h.s. p.r.n.
12. Calcium Carbonate one gram p.o. q.d.

DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease DISEASE .
2. Ulcerative colitis status post ileostomy.
3. Left below the knee amputation.
4. Aortic stenosis status post porcine aortic valve
replacement.
5. Acute renal failure DISEASE which is resolving.




[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 4263**]

Dictated By:[**Last Name (NamePattern1) 6857**]
MEDQUIST36

D: [**2104-8-25**] 18:28
T: [**2104-8-25**] 19:36
JOB#: [**Job Number 6858**]
Admission Date: [**2104-11-19**] Discharge Date:


Service: [**Hospital1 139**]

CHIEF COMPLAINT: Dehydration nausea vomiting and increased
ostomy output.

HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female with history of ulcerative colitis DISEASE status post
ileostomy in [**2087**] with severe COPD DISEASE and a past admission for
severe diarrhea DISEASE which led to acute renal failure DISEASE who was in
her usual state of health until 4-5 days prior to admission
when a VNA nurse noted increased output from her ostomy. She
also was complaining of decreased po intake and post tussive
vomiting DISEASE at that time. Dr. [**Last Name (STitle) **] went to the patient's
house on the day of admission and felt she should come to the
Emergency Room for evaluation. She was also stating that she
had a slight increase in shortness of breath DISEASE above baseline.
In the Emergency Room she was orthostatic DISEASE but afebrile and
was found to have acute renal failure DISEASE with a BUN of 71
creatinine up to 3.8 and a potassium of 6.6. ABG at that
time showed PH of 7.18 PCO2 31 and a PO2 of 114. EKG showed
peaked T waves. She was given bicarbonate and Albuterol nebs
and hydrated with four liters of normal saline. She then was
transferred to the MICU for further care.

PAST MEDICAL HISTORY: 1) Ulcerative colitis DISEASE status post
ileostomy in [**2097**]. 2) Left BKA. 3) Aortic stenosis status
post porcine valve replacement. 4) Cardiac catheterization
in [**3-6**] showed no evidence of coronary artery disease DISEASE . 5)
History of acute renal failure DISEASE secondary to dehydration DISEASE . 6)
Chronic obstructive pulmonary disease DISEASE with the most recent
PFTs on [**2104-7-15**] showing an FVC of 54% predicted value and
FEV1 of 24% predicted value and an FEV1 to FVC ratio of 45%.
Patient's O2 sat is 91% at baseline on room air. 7)
Perioperative MI in [**2097**] with persistent Q's in leads 2 3
and AVF.

ALLERGIES: Patient is allergic DISEASE to Penicillin Codeine
Demerol Procardia and Aspirin.

MEDICATIONS: On admission Albuterol and Atrovent nebs
Atenolol 25 mg po bid Vanceril MDI 4 puffs [**Hospital1 **] Zantac 150
mg po q d Isordil 10 mg po tid Elavil 10 mg po q h.s. prn
and a Multivitamin po q d.

FAMILY HISTORY: The patient's daughter and her grandchildren
have a history of asthma DISEASE . She also has a daughter with
emphysema DISEASE .

SOCIAL HISTORY: The patient currently lives alone. She has
nine children. She uses a wheelchair as well as a prosthesis
to ambulate. She is a retired customer service analyst at
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 15 years ago. She has a 30 pack year smoking
history. She quit approximately 10 years ago. She denies
any alcohol use.

PHYSICAL EXAMINATION: Temperature 95.5 heart rate 85 blood
pressure 120/70 respiratory rate 25 pulse ox 99% on two
liters. In general the patient is an elderly female who is
tachypneic DISEASE at rest. HEENT: Revealed dry mucus membranes
pupils are equal round and reactive to light extraocular
movements intact. Conjunctiva are pink and non injected.
The sclera are anicteric. The neck has no JVD. There was no
lymphadenopathy DISEASE . The carotids are 2Admission Date: [**2106-9-17**] Discharge Date: [**2106-9-23**]


Service: MICU

HISTORY OF PRESENT ILLNESS: Eighty-year-old female with
history of end-stage COPD DISEASE aortic valve replacement and
nursing home residency brought to Emergency Room from nursing
home after complaining of increased chest pressure and
unresponsive with nitroglycerin and increasing shortness of
breath with a productive cough DISEASE of white sputum. The patient
has chronic chest pain DISEASE but usually responds to
nitroglycerin. The patient has chronic shortness of breath DISEASE
with cough DISEASE but more so since [**9-15**] at which point she
was seen by her PCP and started on levofloxacin.

The shortness of breath DISEASE increased with chest pressure since
that point and she called for help because she thought she
was having a heart attack. In the Emergency Room the
patient had chest pressure and EKG showed evidence of an old
inferior MI DISEASE and rate related ST-T wave changes. The patient
also had increased blood pressure up to 220/100 with a heart
rate of 116. The patient was started on nitroglycerin drip
given Lasix 40 mg IV x1 multiple albuterol and Atrovent
nebulizers Solu-Medrol 125 mg IV x1 and Zestril 20 mg p.o.
x1 in the ED.

The patient had an ABG showing a pH of 7.17 a CO2 of 75 and
an oxygen of 96 on nasal cannula and was started on BiPAP at
that point. The VBG on BiPAP was a pH of 7.23 CO2 64 and
oxygen 172. Patient was then switched to 1 liter/minute
nasal cannula and had an ABG of 7.25 58 and 74.

Patient was observed to be in respiratory distress DISEASE with
tachycardia DISEASE and the decision was made to restart BiPAP and
observe in the MICU.

PAST MEDICAL HISTORY:
1. Ulcerative colitis DISEASE status post total colectomy in [**2087**].
2. COPD DISEASE : Chronic productive cough chronic DISEASE shortness of
breath chronic 2 liters nasal cannula O2 at baseline.
3. Aortic valve replacement in '[**99**] porcine valve.
4. Status post left below the knee amputation.
5. MI.
6. Upper GI bleeding DISEASE .
7. Hypertension DISEASE .

ALLERGIES:
1. Procardia.
2. Demerol.
3. Penicillin.
4. Codeine.
5. Diltiazem.

MEDICATIONS:
1. Levofloxacin 500 mg p.o. q.d.
2. Atenolol 50 mg p.o. q.d.
3. Imdur 30 mg p.o. q.d.
4. Ativan.
5. Zestril 20 mg p.o. q.d.
6. Claritin 10 mg p.o. q.d.
7. Multivitamin.
8. Protonix 40 mg p.o. q.d.
9. Albuterol.
10. Tylenol.
11. Guaituss.
12. Ambien.
13. Aspirin 81 mg p.o. q.d.
14. Flovent.
15. Flonase.
16. Serevent.
17. Tums.
18. Vitamin C.
19. Ocean spray.

PHYSICAL EXAM DISEASE : Vital signs: Temperature 98.4 pulse 103
blood pressure 130/52 respirations are 22 and 97%
saturation on 4 liters/minute nasal cannula. In general
elderly female sitting up in bed pursed-lip breathing with
use of accessory muscles able to say short sentences alert
and oriented times three. Head: Pupils are equal round
and reactive to light. Extraocular movements DISEASE are intact.
Oropharynx is clear. Dry mucosal membranes. Neck: JVD to
10 cm no bruits DISEASE . Cardiovascular: 3/6 systolic murmur with
loud S1 at left upper sternal border regular rate and
rhythm. Pulmonary: Decreased breath sounds [**4-6**] of the way
up bilaterally. Decreased fremitus DISEASE bilaterally poor air
movement diffusely. Abdomen is soft nondistended and
nontender. Positive bowel sounds. Positive ostomy bag with
gas and dark green stool. Extremities: Status post left
below the knee amputation right heel in soft bootie. No
clubbing cyanosis DISEASE or edema DISEASE .

LABORATORIES: White count 14.7 with 81% neutrophils
hematocrit 36.3 platelets 338. Coags were normal. Chem-7
unremarkable. No anion gap. Urinalysis remarkable only for
500 of protein. Patient was cycled for cardiac enzymes with
a peak CK of 108 peak MB of 11 and troponin of 0.07.

INITIAL IMPRESSION: Eighty-year-old female with end-stage
COPD DISEASE status post aortic valve replacement with acute COPD DISEASE
exacerbation and slight troponin elevation.

HOSPITAL COURSE:
COPD DISEASE flare: The patient was maintained on a regimen of IV
steroids antibiotics frequent nebulizer treatments and
chest PT and was observed in the MICU. The patient was
noted to desaturate while not on BiPAP and retained CO2 and
was thus placed on intermittent BiPAP for support. The
patient did not tolerate BiPAP well needing benzodiazepines
and occasional Haldol for sedation.

The patient's respiratory status did improve so that the
patient was able to tolerate longer periods off BiPAP in the
MICU and at that point she communicated to us that she no
longer wished to be place back on BiPAP and that she wished
to be made DNR/DNI comfort measures only. Her family was
present for this decision and agreed. The patient at that
point the patient did not have BiPAP placed back on quickly
desaturated over the course of the day and expired.

DISCHARGE DIAGNOSIS: Chronic obstructive pulmonary disease DISEASE
exacerbation.

DISCHARGE CONDITION: Deceased.



[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 3795**]

Dictated By:[**Name8 (MD) 6867**]

MEDQUIST36

D: [**2106-11-15**] 13:50
T: [**2106-11-16**] 05:24
JOB#: [**Job Number 6868**]
Admission Date: [**2181-8-26**] Discharge Date: [**2181-8-29**]

Date of Birth: [**2106-9-20**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
atrial fibrillation DISEASE and hypotension DISEASE

Major Surgical or Invasive Procedure:
Cardioversion for unstable atrial fibrillation DISEASE
PICC placement

History of Present Illness:
74 Russian speaking male w/ history of dementia depression DISEASE
remote CAD afib s/p pacer now being admitted for increased
lethargy obtundation fever atrial fibrillation DISEASE and
hypotension DISEASE 64/30 and tachypnea DISEASE 32-34.
.
On review of the notes from [**Hospital 100**] rehab patient was lethargic
since [**2181-8-18**]. Olanzapine namenda and depakote stopped. His BP
had been 80-90/40-50 and P90s. On day of admission he spiked
fever DISEASE to 103 w/ AF w/ RVR and more hypotension DISEASE . His [**Month/Day/Year 802**] was
called and the decision was to admit him.
.
On arrival to the ED his vital signs were T102.6 P180 BP64/30.
Due to unknown code status at the time cardioversion was
attempted twice w/ 50 and 100J but to no avail. He was given 5L
NS. He was also started on vanco/levo/flagyl. Later phone call
to NH claims that he is DNR/DNI
.
On arrival to the ICU phone calls were made to [**Hospital 100**] rehab
PCP([**Doctor First Name **] O/[**Location (un) **]) brother(HCP) and Nice([**Doctor First Name **] who claims
to be legal guardian. [**Name (NI) **] Rehab claims that he is DNR/DNI.
Brother deferred all decision making to [**Doctor First Name **]. [**Doctor First Name **] claims to be
legal guardian and wants to patient to be full code regardless
of situation. PCP did not call back at the time of admission.


Past Medical History:
1. Atrial fibrillation DISEASE s/p pacemaker placement not
anticoagulated [**3-1**] med non-adherence and fall risk. EP had
apparently evaluated his pacer which was thought to be
functional. Rate control was noted to be difficult given pt's
agitation DISEASE and often refusal/non-compliance w/ po agents.
2. Dementia/personolity disorder DISEASE as above frequently required
chemical/mechanical restraintAdmission Date: [**2198-5-22**] Discharge Date: [**2198-5-27**]

Date of Birth: [**2149-8-20**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain DISEASE

Major Surgical or Invasive Procedure:
[**2198-5-22**] - CABGx4 (Left internal mammary -Admission Date: [**2130-12-14**] Discharge Date: [**2130-12-16**]

Date of Birth: [**2057-1-13**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
transient hypotension DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
73 year old male with a history of Type II diabetes CAD DISEASE s/p
CABG PVD DISEASE who presented to the [**Hospital1 18**] ED with fever DISEASE and weakness DISEASE .
Patient reports that he was in his USOH until 1 night PTA when
his son noted that his Admission Date: [**2154-4-30**] Discharge Date: [**2154-5-3**]

Date of Birth: [**2092-11-28**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Percocet

Attending:[**First Name3 (LF) 12**]
Chief Complaint:
fever chills rigors DISEASE

Major Surgical or Invasive Procedure:
Arterial line placement

History of Present Illness:
61F w/ sign PMH for UC DISEASE s/p colectomy Stage II breast cancer DISEASE
presented on day 13 of second cycle of chemotherapy with fever DISEASE
to 100.6 at home w/ severe rigors DISEASE . She took two Ibuprofen at
home and then went to onc clinic today where she was then
referred to the ED for admission. She stated that for the past
two days she has noticed an increasing amount of stool output in
her ostomy bag but denies abdominal discomfort or blood in her
stool. She has had nausea DISEASE but similar to how she has felt in the
past with chemo. She also mentioned that she recently cut her
finger in the garden on Sunday which is now red and slightly
tender to the touch. She otherwise denies any vomiting rash DISEASE
rhinorrhea dysuria cough DISEASE SOB or abdominal discomfort. She
denies any recent travel or sick contacts as well.
.
In the ED inital vitals were Temp: 101 Admission Date: [**2117-9-12**] Discharge Date: [**2117-9-13**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
coffee ground emesis DISEASE

Major Surgical or Invasive Procedure:
placement of R femoral Cordis resuscitation line


History of Present Illness:
87 yo F with multiple medical problems who presents with coffee
ground emesis DISEASE from [**Hospital **] rehab.
.
In the ED the patient had NG lavage that showed 200cc coffee
ground emesis DISEASE . Additionally the patient received 5 L NS and 2U
of PRBCs. Additionally she was given vancomycin flagyl and
levofloxacin for concern of infection DISEASE . CXR showed possible free
air and surgery was contact[**Name (NI) **]. However it was confirmed that
the family does not want surgery and thus the patient did not
have a formal [**Doctor First Name **] consult. BPs were briefly low in the ED and
the patient was started on levophed. However after further
discussions with the family it was determined that the family
would like to direct the care more towards comfort and the
levofed was stopped.
.
Upon arrival to the MICU the patient appeared to be in pain DISEASE .
After extensive family discussion they decided that the patient
should not be intubated and would not be a candidate for
surgery. Additionally they would like to keep the patient
comfortable.


Past Medical History:
1. Diabetes DISEASE
2. HTN DISEASE
3. Hypercholesterolemia DISEASE
4. Arthritis DISEASE
5. Hypothyroid DISEASE
6. S/p nephrectomy for renal cell ca done in 94 at BU
7. MRegurgitation
8. Chronic abdominal pain DISEASE
9. H/o pancreatitis DISEASE
10. pancreas divisum
11. hiatal hernia DISEASE repair
12. left colectomy [**3-12**] [**Location (un) 6553**] b 2 colon cancer with neg nodes
13. ccy

Social History:
No tob no etoh no narcotics lives in [**Hospital1 **] House. Three
daughters currently seeking healthcare proxy.


Family History:
NC

Physical Exam:
VS: T 96.8 Hr 63 BP 119/93 RR 20 02 93% 3L--Admission Date: [**2155-10-1**] Discharge Date: [**2155-10-24**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Dyspnea DISEASE

Major Surgical or Invasive Procedure:
EGD
Paracentesis

History of Present Illness:
83 y.o. male with h/o CHF DISEASE EF Admission Date: [**2123-3-26**] Discharge Date: [**2123-3-29**]

Date of Birth: [**2064-4-28**] Sex: M

Service: Coronary Care Unit

HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old man
with history of coronary artery disease DISEASE status post inferior
myocardial infarction DISEASE [**2113-4-28**] with stent to the right
coronary artery angioplasty to the obtuse marginal in
[**Month (only) 359**] of '[**14**] stent to the right coronary artery in
[**2114-11-28**] angioplasty to the posterolateral branch of
the right coronary artery in [**2116-6-28**] who presented with
unstable angina x3 weeks to an outside hospital. Patient
states that he has been chest pain DISEASE free for approximately
seven years prior to approximately three weeks ago when his
chest pain DISEASE recurred.

Patient reports that the chest pain DISEASE was his typical angina
but mild compared to previous experiences and resolved with
1-2 nitroglycerin. these symptoms sometimes occurred at rest
over the past three weeks. His episodes have increased in
frequency over the past three weeks. Patient denies any
associated symptoms such as shortness of breath nausea DISEASE or
vomiting DISEASE .

On the evening of admission the patient awoke from sleep
with 9/10 chest pain DISEASE and diaphoresis DISEASE and took six sublingual
nitroglycerin as well as aspirin without resolution of chest
pain DISEASE so he called ambulance. Patient was brought to an
outside hospital where ECG changes showed inferior ST
elevations and anterior ST depressions. Patient received
Heparin drip Morphine and nitroglycerin at the outside
hospital and became chest pain DISEASE free. Patient also received
Retavase at the outside hospital.

Patient had been scheduled for elective cardiac
catheterization at [**Hospital1 **] therefore he was
transferred to [**Hospital1 **] [**First Name (Titles) **] [**2123-3-26**] the
same evening that he presented to the outside hospital. In
the ambulance upon transfer patient had recurrent chest pain DISEASE
and received a second dose of Retavase. The patient's
inferior ST changes had resolved by the time he arrived at
the Emergency Room at [**Hospital1 **] and he was
originally pain DISEASE free. However his pain DISEASE recurred and a
repeat electrocardiogram showed ST elevations approximately 1
mm in the inferior leads st depression DISEASE in V1 and V2 and 1 & avl
with t wave inversion in avl.The patient was therefore brought
from the Emergency Room to the Coronary Cath Laboratory.

At catheterization the patient was found to have 80% mid
left circ stenosis DISEASE as well as 90% lesion in the RCA between
two previous stents. The patient received two hepacoat stents to
his
right coronary artery with good flow afterwards. Patient was
then transferred to the Coronary Care Unit for further
management. Upon arrival at the Coronary Care Unit the
patient denied any symptoms such as chest pain DISEASE or shortness
of breath.

Review of systems was notable for skin lesions that the
patient states has been diagnosed as shingles.

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE .
2. Hypertension DISEASE .
3. Hypercholesterolemia DISEASE .
4. Cirrhosis DISEASE secondary to alcohol use which per the patient
has resolved.
5. Status post cholecystectomy.

SOCIAL HISTORY: Patient smokes [**9-7**] cigarettes per day.
Also drinks alcohol socially but denies drug use.

FAMILY HISTORY: [**Name (NI) **] mother passed away from a
myocardial infarction DISEASE in her 70s and patient's father passed
away from a myocardial infarction DISEASE in his 50s.

REVIEW OF SYSTEMS: Was otherwise noncontributory.

PHYSICAL EXAM ON ADMISSION: Middle-aged gentleman lying in
bed in no apparent distress with normal S1 S2 regular rate
and rhythm with no murmurs or extra heart sounds. Patient's
vital signs: Heart rate in the 70s respiratory rate 18
blood pressure 104/69 height 6'0Admission Date: [**2112-5-7**] Discharge Date: [**2112-7-7**]


Service: GENERAL SURGERY

HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old man
with a history of coronary artery disease DISEASE status post
coronary artery bypass graft times three in [**2104-2-26**] hypertension DISEASE aortic insufficiency and hiatal hernia DISEASE
who presented with postprandial epigastric pain DISEASE followed by
nausea DISEASE and vomiting DISEASE . The patient denied any shortness of
breath diaphoresis palpitations DISEASE . He states that this pain DISEASE
is different from the pain DISEASE that he had when he had his
myocardial infarction DISEASE . When seen in the Emergency Room the
patient was given aspirin morphine heparin and he was
admitted to rule out myocardial infarction DISEASE . The patient's
amylase and lipase were found to be elevated consistent with
pancreatitis DISEASE .

PAST MEDICAL HISTORY:
1. Coronary artery bypass graft in [**2104**].
2. Hypertension DISEASE .
3. Aortic insufficiency.
4. Hiatal hernia DISEASE .
5. Echocardiogram with an ejection fraction of 44 to 48%.

MEDICATIONS:
1. Lopressor.
2. Aspirin.

ALLERGIES: No known drug allergies DISEASE .

HOSPITAL COURSE: The patient was admitted to the Medical
Service in which care I did not partake in during that time.
The patient was seen by General Surgery for a consultation of
abdominal pain DISEASE . The rest of his labs included ALT 15 AST
21 alkaline phosphatase 99 total bilirubin 0.7 amylase
111 lipase 164 albumin 3.

The patient underwent an extensive work-up which eventually
revealed that he had an obstructing lesion at the fourth part
of the duodenum and proximal jejunum at the area of the
ligament of Treitz and therefore was taken for an
exploratory laparotomy on [**2112-5-20**]. The patient had a
exploratory laparotomy and lysis of adhesions DISEASE takedown of
splenic flexures biopsy of peritoneal metastases
duodenal-jejunal bypass placement of feeding jejunostomy
tube. Please see Operative Note for further detail.

Postoperatively the patient was admitted to the Surgical
Intensive Care Unit for a week for close cardiac monitoring.
The patient afterwards continued to have nausea DISEASE and
vomiting DISEASE . The patient had a prolonged ileus DISEASE and gastroparesis DISEASE
which became evident postop and likely stemmed from
longstanding duodenal obstruction DISEASE as well as his age and
physical status which required TPN use. The patient
tolerated tube feeds well. Once TPN was discontinued the
[**Hospital 228**] hospital stay was thus characterized as slowly
progressing nutrition p.o. and then there would be episodes
of nausea DISEASE and vomiting DISEASE then the patient would start over with
tube feeds p.o. and his feedings were slowly advanced.
UGI study showed that the contrast passed through the native
duodenum as well as the bypasss loop and upper endoscopy
showed that the duodenojejunostomy was widely patent. Thus
he was treated with reglan and erythromycin for gastroparesis DISEASE
with slow improvement clinically.

His cultures while in the hospital: He had transient episode
of urinary sepsis DISEASE and urine cultures at that time showed
Pseudomonas treated with IV antibiotics and then
CiprofloxacinAdmission Date: [**2190-7-14**] Discharge Date: [**2190-7-19**]

Date of Birth: [**2130-9-22**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 59 year old
male with a history of Parkinson's disease DISEASE status post deep
brain electrode placement who was transferred to [**Hospital1 346**] for atrial fibrillation DISEASE and flutter DISEASE
with slow ventricular response and symptomatic bradycardia DISEASE .
On the day prior to admission the patient noted an episode
of dyspnea weakness DISEASE and diaphoresis DISEASE which was more severe
than he had ever experienced before and was found by his
nurse to have a heart rate in the 40s and systolic blood
pressure in the 90s. Electrocardiogram demonstrated atrial
flutter with 5:1 block. He was started on Dopamine to
maintain his blood pressure and then entered a junctional
rhythm. He was then noted over the next 12 hours to go in
and out of sinus as well as atrial fibrillation DISEASE . The patient
has had recurrent symptoms of light-headedness DISEASE and
diaphoresis DISEASE but is not certain if they correlate with
changes in his heart rhythms. The patient's only new
medications have been Kefzol and Terazosin. He denies any
fever DISEASE or chills DISEASE but has had chest tingling DISEASE and numbness DISEASE . Of
note the patient had the power generators placed for his
deep brain electrode stimulation on [**2190-7-1**] and they were
recently turned on. He was admitted to [**Hospital1 190**] from [**2190-7-7**] to [**2190-7-11**] for a question of
superficial skin infection DISEASE status post pacer power generator
placement and was discharged on a fourteen day course of
Kefzol.

PAST MEDICAL HISTORY:
1. Parkinson's disease DISEASE .
2. Depression.
3. Status post subthalamic deep brain electrode placement.
4. Pyloric stenosis status post pyloroplasty.

ALLERGIES:
1. Paxil.
2. Cogentin.

MEDICATIONS ON ADMISSION:
1. Amantadine 100 mg p.o. three times a day.
2. Sinemet 25/250 mg one half tablet q3hours while awake.
3. Carbamazepine 200 mg p.o. twice a day.
4. Tolterodine 1 mg p.o. twice a day.
5. Klonopin 0.5 mg p.o. q.a.m.
6. Quinine 325 mg p.o. twice a day.
7. Mirapex 0.5 mg p.o. at 0500 0900 1300.
8. Mirapex 0.25 mg p.o. at 1800.
9. Trazodone 150 mg p.o. q.h.s. p.r.n.
10. Kefzol two grams intravenously q8hours until [**2190-7-21**].
11. Terazosin 10 mg p.o. once daily.

SOCIAL HISTORY: The patient denies any tobacco history. He
has distant alcohol use. He lives at home alone.

FAMILY HISTORY: The patient denies any history of coronary
artery disease DISEASE or arrhythmias DISEASE in his family.

PHYSICAL EXAMINATION: On physical examination the patient
was afebrile temperature 99.6 heart rate 75 blood pressure
150/80 respiratory rate 20 oxygen saturation 96% on two
liters via nasal cannula. In general the patient is an
obese male in no apparent distress. Head and neck
examination revealed anicteric sclera. The pupils are equal
round and reactive to light and accommodation. Extraocular
movements are intact. Neck supple and no carotid bruits DISEASE .
The lungs were clear to auscultation bilaterally. The chest
wall had two well healed surgical incisions approximately 4.0
centimeters in length with no drainage or erythema DISEASE on his
bilateral anterior chest. Cardiac examination revealed an
irregularly irregular rhythm with no murmurs. The abdomen
was benign. The extremities had no edema DISEASE with 2[** **] Date: [**2197-6-25**] Discharge Date: [**2197-6-28**]

Date of Birth: [**2130-9-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
AnticholinergicsOther / Eldepryl / Amitriptyline / Cogentin /
Paxil

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Falls

Major Surgical or Invasive Procedure:
RIJ placement

History of Present Illness:
66 yo man from NH with h/o parkinson's disease DISEASE s/p deep brain
stimulation presented from [**Hospital3 **] s/p fall x 3 in last
2 days. Struck head with one fall (transitioning from wheelchair
to chair) hit his head on carpet. Some dysuria DISEASE no fevers DISEASE some
SOB. No HA no LOC no seizures DISEASE no weakness/pain.
.
In the ED initial vs were: T 99.5 HR74 BP149/79 RR18 O2Sat97.
Then spiked to 100.5. Was given APAP. UA positive with
leukocytosis. Patient was given cipro levophed for five minutes
but developed CP while he was on it so it was discontinued.
While in ED had afib with RVR with rate in 140s. Now 120s.
Hypotensive DISEASE to SBP80s with that HR. RIJ CVL was placed. CXR
pending. EKG without changes per ED physician. [**Name10 (NameIs) **] to unit
for hypotension/tachycardia.
.
VS: HRs 107-110s BP101/83 RR 30 O2Sat:94% on 2L NC
.
On the floor patient had some low back pain DISEASE initially when
getting situated in bed but this resolved quickly. Otherwise he
had no complaints specifically no complaints of SOB chest pain DISEASE
dizziness palpitations DISEASE .


Past Medical History:
# Parkinsons disease DISEASE X 17 years s/p deep brain stimulation [**2190**]
followed by Dr. [**First Name (STitle) **]
# Chronic LBP DISEASE
# SSS (aflutter with severe bradycardia DISEASE ) s/p [**Company 1543**] Sigma
dual-chamber pacemaker followed by Dr. [**Last Name (STitle) **]
# Superficial thrombophlebitis DISEASE [**5-13**] treated briefly with lovenox

# HTN DISEASE
# Obesity DISEASE


Social History:
Retired. Multiple jobs before. He currently resides at [**Location (un) 6927**] Rest Home ([**Hospital3 **]). They administer his meds
to him. He denies tobacco or alcohol use. Walks with a walker
[**3-7**] parkinsons disease.


Family History:
Great Aunt with Parkinson's Disease DISEASE . Daughter and son are
healthy.

Physical Exam:
General: Alert oriented no acute distress masked facies DISEASE
HEENT: Sclera anicteric MMM oropharynx clear
Neck: supple JVP not elevated no LAD
Lungs: Clear to auscultation bilaterally no wheezes rales DISEASE
ronchi
CV: Irregularly irRegular rhythm tachycardic normal S1 Admission Date: [**2162-12-21**] Discharge Date: [**2163-1-3**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Penicillins / Percocet

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
80 year old white female with DOE for the past year.

Major Surgical or Invasive Procedure:
Aortic valve replacement(21mm CE Perimount) [**2162-12-21**]


History of Present Illness:
This 80 year old white female has had DOE for 1 year. An echo
in [**3-11**] showed [**Location (un) 109**] of 0.8 cm2. She underwent cardiac cath on
[**2162-11-15**] which revealed: AV peak gradient of 64mmHg [**Location (un) 109**] of
0.46 cm2 30% LMCA 40% D1 lesion 50% RCA stenosis DISEASE and
pulmonary HTN DISEASE . She is now admitted for elective AVR.

Past Medical History:
HTN DISEASE
Admission Date: [**2163-8-11**] Discharge Date: [**2163-8-15**]


Service: ORTHOPAEDICS

Allergies DISEASE :
Penicillins / Percocet / Heparin Agents

Attending:[**First Name3 (LF) 64**]
Chief Complaint:
CC: Left hip pain DISEASE


Major Surgical or Invasive Procedure:
[**2163-8-11**] Hip surgery

History of Present Illness:
HPI: 81 yo woman w/ PMH sig for s/p bovine AVR periop A.Fib(on
coum and amio) HTN DISEASE CAD PTCA X2 PVD hypercholesterolemia DISEASE was
walking with a cane got stuck in a rug and fell forward and onto
her left hip. Denied any dizziness lightheadedness DISEASE
CP/palpitations and LOC after fall. Admitted to OSH reveled a
L hip fracture DISEASE . Preop negative nuclear stress. She was at the
OSH x 2d and admitted to ortho for Hip fracture.
.
Given preoperative FFP and she underwent an uncomplicated ortho
procedure screw placed. Post op course notable for some hives
on thigh and left ear given 25 benadryl X 1. Pt also noted to
be brady to 50s DISEASE not symptomatic no intervention and
transferred to medicine this morning.
.
Now pt states that the pain DISEASE is controlled with medications. She
has not moved her bowels since monday. not passing gas but pt
withholding voluntarily. Admission Date: [**2168-8-26**] Discharge Date: [**2168-9-2**]


Service: MEDICINE

Allergies DISEASE :
Penicillins / Percocet / Heparin Agents

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
thoracentesis

History of Present Illness:
Ms. [**Known lastname 6940**] is an 86 year old female with diastolic CHF DISEASE afib
CAD [**Known lastname 1192**] MS/MR s/p bioprosthetic AVR ([**2162**]) and h/o CVA
who presents with shortness of breath DISEASE on transfer from
[**Location (un) 5871**]/OSH.
.
Patient was doing okay at home 24hr home O2 3-4L until this
morning when her daughter thought she was more short of breath
and tachypneic. Per daughter patient had a high Admission Date: [**2109-5-16**] Discharge Date: [**2109-5-19**]

Date of Birth: [**2048-9-16**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
R arm pain swelling erythema DISEASE


Major Surgical or Invasive Procedure:
NONE


History of Present Illness:
Mr. [**Known lastname 6943**] is a 60 y/o male with polycythemia DISEASE [**Doctor First Name **] for past 20Admission Date: [**2172-3-26**] Discharge Date: [**2172-4-23**]

Date of Birth: [**2109-12-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Febrile DISEASE unresponsive--Admission Date: [**2166-6-10**] Discharge Date: [**2166-7-4**]

Date of Birth: [**2135-2-7**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
sepsis DISEASE

Major Surgical or Invasive Procedure:
PEG placement
Intubation tracheostomy
Central line


History of Present Illness:
This is a 31 yo F with a past medical history significant for
hemorrhagic CVA DISEASE 3 years ago with a prolonged post CVA DISEASE course
c/b tracheostomy and residual aphasia DISEASE and r-sided hemiparesis DISEASE
aspiration pneumonias DISEASE who per her mother has had a recent
progressive decline with difficulty swallowing. On the day of
admission to the OSH the patient developed abdominal pain DISEASE and
vomiting DISEASE and was admitted for further work-up. She was found to
be tachycardic to the 140's febrile DISEASE to 103.8 (rectal) BP
138/114. A femoral line was placed as PIV access and a RIJ were
unable to be obtained. She had progressive respiratory distress DISEASE
and was then intubated for airway protection. She was
transferred to the OSH ICU for presumed aspiration pneumonia DISEASE
sepsis ARF DISEASE and respiratory failure DISEASE .
.
At the OSH the patient was started
levofloxacin/timentin/vancomycin OG tube was placed was given
IVF and was placed on steroids. Per her mother she has no
seizure DISEASE history but is maintained on valproate and was
restarted on this at the OSH. She was transferred to [**Hospital1 18**] to
the [**Hospital Unit Name 153**] for further management of her renal failure DISEASE and
possible sepsis DISEASE .
.
When the patient arrived she was on a propofol gtt and was
having tongue and eyelid fasciculations DISEASE . She withdrew to pain DISEASE
but was otherwise unresponsive. Vitals were stable.

Past Medical History:
- Diabetes Mellitus DISEASE type 1 (dx at age 3) hx of hypoglycemic
episodes
- CVA ( hemorrhagic DISEASE ) at 27 with residual aphasia DISEASE and
r-hemiparesis tracheostomy post CVA now decannulated.
- blindness in one eye
- history of aspiration pneumonia DISEASE
- although patient is on valproate no reported history of
stroke DISEASE
- depression DISEASE

Social History:
remote smoking history at age 18 lived in CA and has lived at
the Greenery since coming to MA.

Family History:
healthy brother/sister. Maternal family history of DM.

Physical Exam:
Vitals: T 99.4 HR 90 BP 138/88 sats 98% on AC 450x16 peep 5
FiO2 60%
General: intubated sedated not responding to voice.
HEENT: left ptosis DISEASE . PERRL. anicteric.
Neck:supple JVP elevated 8cmH20
Lungs: diffuse rhonchi
Chest: RRR II/VI sem at base
Abd: soft NT mild distention Admission Date: [**2166-7-13**] Discharge Date: [**2166-8-14**]

Date of Birth: [**2135-2-7**] Sex: F

Service: EMERGENCY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
seizure hypoglycemia DISEASE

Major Surgical or Invasive Procedure:
trans-esophageal echocardiogram
bronchoscopy


History of Present Illness:
31yoF w/ h/o DM1 HTN DISEASE s/p left sided hemorrhagic CVA DISEASE (3 yrs
ago) s/p trach/PEG/chronically indwelling catheter presents to
ED from [**Hospital **] rehab today after having had witnessed Admission Date: [**2167-1-16**] Discharge Date: [**2167-1-24**]

Date of Birth: [**2135-2-7**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Fevers and Emesis

Major Surgical or Invasive Procedure:
IR-guided Midline IV [**2167-1-23**]

History of Present Illness:
31yoF with DM1 HTN DISEASE and R hemiplegia DISEASE and aphasia DISEASE s/p CVA DISEASE who
presented from NH with fevers DISEASE to 101F and emesis DISEASE . She was
febrile DISEASE and hyperglycemic in DKA DISEASE for which she was admitted to
the MICU.
.
MICU course: She was admitted for DKA hypernatremia DISEASE and UTI DISEASE
Admission Date: [**2171-7-5**] Discharge Date: [**2171-7-12**]

Date of Birth: [**2135-2-7**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Endotracheal intubation at OSH prior to arrival extubated at
[**Hospital1 18**]
Temporary Dobhoff tube placement for tubefeeds


History of Present Illness:
36 y.o female with pmhx of CVA DISEASE [**2158**] DM type 1 found to be
unresponsive with a serum glucose of 28. She developed seizure DISEASE
like activity and hypoxemia DISEASE at [**First Name4 (NamePattern1) 189**] [**Last Name (NamePattern1) **] where she was
intubated with return of secretions from ETT. The seizure DISEASE like
activity improved with ativan. Neurology consulted for continued
twitches EEG ordered loaded with Dilantin in ED. Recieved
total 6mg Ativan with control of sz-like activity. Given empiric
abx: Vanc/Unasyn initially now Vanc/Zosyn. Has had Klebs UTIs DISEASE
Resistant only to ampicillin in their system.Cultures are
currently pending and has left sided infiltrate on imaging.
.
Of note the patient was hypothermic initially now normothermic
with
WBC 11.5 BMP wnl BUN 21 Cr 1.4 ABG 7.35/35/170 Trop neg.
( DM1 DISEASE )
No LP was done. She just came in this morning at 7amAdmission Date: [**2139-3-24**] Discharge Date: [**2139-3-27**]

Date of Birth: [**2070-5-3**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headaches cerebral aneurysm DISEASE

Major Surgical or Invasive Procedure:
Endovascular angiogram


History of Present Illness:
68 year old female who is known to the neurosurgical service for
known R ICA aneurysm DISEASE 3mm reported in 10/[**2137**]. She was seen in
[**10-12**] in our office for incidentaly DISEASE found R ICA aneurysm DISEASE and has
not been seen since.

Pt reports HA with sudden onset about 6 - 7 days ago without
improvement. Pt with emesis DISEASE x last 3 days - intolerant of food/
liquids and meds. Describes emesis DISEASE as projectile. Pt went to
PCP last friday and had o/p CT. That CT reported Admission Date: [**2160-3-20**] Discharge Date: [**2160-4-4**]


Service: MED

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old gentleman
with a history of congestive heart failure DISEASE with the last
echocardiogram prior to examination revealing an ejection
fraction of 75 percent with 3Admission Date: [**2147-4-18**] Discharge Date: [**2147-4-25**]

Date of Birth: [**2071-4-24**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pressure with exertion


Major Surgical or Invasive Procedure:
[**2147-4-21**]
Coronary artery bypass grafting x3 with
left internal mammary artery graft to left anterior
descending reverse saphenous vein graft to the marginal
branch and diagonal branch.


History of Present Illness:
75 year old male with history of diabetes DISEASE and hyperlipidemia DISEASE
referred by PCP for exercise stress test for symptoms of chest
discomfort with exertion. He reports that he is quite active but
recently has noticed that his walking is limited by left sided
chest pressure that resolves with rest. ETT demonstrated 2-4 mm
horizontal ST segment depressions inferiorly and in leads V4-V6.
In addition ST segment elevation was noted in lead aVR. He was
also symptomatically hypotensive DISEASE with lightheadedness DISEASE . He now
underwent cardiac catheterization that revealed significant
coronary artery disease DISEASE .

Past Medical History:
coronary artery disease DISEASE s/p CABG
hypertension DISEASE
hyperlipidemia DISEASE
type 2 DM
pericarditis DISEASE [**2089**]
recent shingles
peripheral neuropathy DISEASE
s/p R 4th trigger finger release
s/p banding internal hemorrhoids DISEASE


Social History:
Lives with wife.
Worked at Sears and the Museum of Fine Arts - now retired.
Denies hx of smoking.
Drinks 2-3 glasses of wine each week.
Denies DISEASE illict drug use.

Family History:
Mother: stroke DISEASE CABG (80s)
Sister: Diabetes DISEASE


Physical Exam:
VS: 125/67 60 18 97%RA
GENERAL: Thin elderly male NAD. Oriented x3. Mood affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL EOMI. Mild erythema DISEASE of
posterior oropharynx
NECK: Supple no JVD no carotid bruits DISEASE
CARDIAC: PMI located in 5th intercostal space midclavicular
line. RR normal S1 S2. No m/r/g. No thrills lifts. No S3 or
S4.
LUNGS: No chest wall deformities scoliosis DISEASE or kyphosis DISEASE . Resp
were unlabored no accessory muscle use. CTAB no crackles
wheezes or rhonchi DISEASE .
ABDOMEN: Soft NTND. No HSM or tenderness DISEASE .
EXTREMITIES: No c/c/e. Left radial site for cath
clean/dry/intact DISEASE good radial pulses no hematoma DISEASE
SKIN: No stasis dermatitis ulcers DISEASE scars or xanthomas DISEASE .
PULSES:
Right: DP 2Admission Date: [**2152-1-20**] Discharge Date: [**2152-1-21**]

Date of Birth: [**2087-10-19**] Sex: M

Service:

HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 5573**] is a 64-year-old
gentleman who underwent heart catheterization on [**2151-12-28**]. On the basis of that test because of multiple vessel
disease it was planned that he go ahead and have coronary
artery bypass graft surgery. The patient had been seen in
[**2149-11-12**] at which time an 80-85% right internal
carotid stenosis DISEASE with no significant stenosis on the left
side was identified by duplex examination. His carotid
disease was asymptomatic and had been asymptomatic in the
intervening two years. At the present time Mr. [**Known lastname 5573 DISEASE **] had
chest pain DISEASE associated with exercise only and after
consultation with the various members of his cardiology team
it was decided to proceed with a carotid endarterectomy on
the right side as a preliminary to his coronary artery bypass
graft procedure.

The patient also has a history of radical prostatectomy and
had previously had a penile implant under the care of Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].

Stress testing on [**2151-12-13**] demonstrated moderately
severe reversible defect in the inferior wall and mild
reversible defect in the anterior wall with an ejection
fraction of 46%.

ADMISSION MEDICATIONS:
1. Zestril 5 mg daily.
2. Procardia 30 mg daily.
3. Atenolol 50 mg daily.
4. Aspirin 162 mg daily.
5. Lipitor 20 mg daily.
6. Imdur 30 mg daily.

PHYSICAL EXAMINATION ON ADMISSION: The patient was a healthy
appearing gentleman with no neurological deficits DISEASE . The
patient had a right carotid bruit. His chest was clear. He
had otherwise normal pulses in the upper extremities and was
otherwise in reasonable cardiac shape for the procedure.

HOSPITAL COURSE: On the day of admission the patient
underwent a right carotid endarterectomy with patch
angioplasty using a thin-walled knitted Dacron. That was
done under general anesthesia. His postoperative course was
completely uneventful. He was discharged to home on the
following day after his surgery taking his usual
medications. He will return for coronary artery bypass graft
in three days.

DISCHARGE DIAGNOSIS: Coronary artery disease DISEASE which was three
vessel in type right carotid stenosis.

OPERATION ON THE DATE OF ADMISSION: Right carotid
thromboembolectomy and patch angioplasty.

MEDICATIONS ON DISCHARGE: As above.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**] M.D. [**MD Number(1) 1478**]

Dictated By:[**Last Name (NamePattern4) 5574**]

MEDQUIST36

D: [**2152-1-21**] 08:13
T: [**2152-1-22**] 06:24
JOB#: [**Job Number 5575**]
Admission Date: [**2152-1-24**] Discharge Date: [**2152-1-28**]

Date of Birth: [**2087-10-19**] Sex: M

Service: CARDIOTHORACIC

HISTORY OF PRESENT ILLNESS: This is a 67 year-old man with a
past medical history significant for noninsulin DISEASE dependent
diabetes mellitus DISEASE as well as prostate cancer DISEASE status post
radical prostatectomy who had previously had a penile implant
under the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5576**]. The patient initially had cardiac
catheterization in [**2142**] following a stress test prior to his
surgery for prostate cancer DISEASE . At that time he underwent
percutaneous transluminal coronary angioplasty of his right
coronary artery which was complicated by a VF arrest DISEASE which
was managed by defibrillation and CPR on [**2142-11-15**].
He then began having exertional anginal symptoms DISEASE last year
however no angina at rest. He also began complaining of
acid reflux symptoms DISEASE beginning in [**2151-9-12**] which was
treated by Prilosec. He underwent a stress test [**2151-12-13**] and subsequently another cardiac catheterization in
[**2151-12-12**] which revealed 80% left anterior descending
coronary artery disease DISEASE 70% left circumflex disease DISEASE and 80%
right coronary artery disease DISEASE with an EF of 45%.

MEDICATIONS PREOPERATIVELY: Procardia Lipitor Atenolol
Imdur Glucophage Zestril and aspirin.

HOSPITAL COURSE: The patient underwent coronary artery
bypass graft times four on [**2152-1-24**] with the left
internal mammary to the left anterior descending saphenous
vein graft to the obtuse marginal saphenous vein graft to
the diagonal and saphenous vein graft to the posterior
descending coronary artery. Total cardiopulmonary bypass
time was 94 minutes total cross clamp time was 50 minutes.
The patient was transferred in stable condition to the
Coronary Care Unit being A paced at 80 beats per minute in
stable condition on neo-synephrine at .5 mcg per kilogram per
minute and Propofol at 30 mcg per kilogram per minute. The
patient was extubated very early postoperative day one
without complications. Postoperative day one the patient
awake alert and oriented times three moving all of his
extremities and following commands in sinus rhythm at 79.
Vital signs are stable with adequate urine output. The
patient's blood sugars were high so an insulin drip was
started per protocol. Still on the neo drip at .25.
Afebrile with a white blood cell count of 9.8 and hematocrit
of 32.6 BUN 16 creatinine .9. The plan for the day was to
wean the patient's neo-synephrine to off. Postoperative day
two no events over the past 24 hours aside from the
neo-synephrine being weaned off. The patient still in sinus
rhythm at 73 vital signs are stable. Afebrile with a white
count of 9.3 and a hematocrit of 28.4. A BUN of 15
creatinine of .8. The plan was to begin the patient's
Lopressor and Lasix.

On physical examination the patient with scattered rhonchi at
the lower bases which clears with coughing. The patient
still is being covered for heparin subQ for fluctuating blood
sugars. The patient was transferred to the floor later
postoperative day two in stable condition with complaints of
mild pain DISEASE at incision sites which was relieved with
Percocet. Urology came by to see the patient because there
was a difficult Foley placement the day of surgery. Urology
then removed the Foley catheter the day of consult which was
[**1-26**] postoperative day two. The patient had no
complaints with voiding and a condom catheter was in place.
Urology explained to the patient that he may leak more then
usual after the dilatation and he was instructed to follow up
with Dr. [**Last Name (STitle) **] after discharge from the hospital.
Postoperative day three the patient awake alert and oriented
with complaints of mild incisional pain DISEASE relieved with
Percocet. The patient's Foley was discontinued and the
patient now complains of incontinence DISEASE since his Foley
removal. Postoperative day four the patient was doing well
with no difficulty urinating. The patient was discharged
home on [**2152-1-28**] with discharge instructions
including follow up with Dr. [**Last Name (STitle) 70**] in four to six weeks
as well as follow up with his cardiologist in two to four
weeks.

DISCHARGE MEDICATIONS: Aspirin 325 mg po q day Atorvastatin
10 mg po q day Metoprolol 12.5 mg po b.i.d. Lasix 20 mg po
q 12 hours Metformin 500 mg po b.i.d. Percocet one to two
tabs po q 4 to 6 hours prn pain DISEASE Colace 100 mg po b.i.d. prn
constipation DISEASE .

DISCHARGE DIAGNOSIS:
Coronary artery disease DISEASE status post coronary artery bypass
grafting.






[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]

Dictated By:[**Doctor Last Name 5577**]

MEDQUIST36

D: [**2152-3-30**] 12:42
T: [**2152-3-31**] 09:31
JOB#: [**Job Number 5578**]
Admission Date: [**2183-8-6**] Discharge Date:


Service: ICU

CHIEF COMPLAINT: Hypercarbic hypoxemic respiratory failure DISEASE

HISTORY OF PRESENT ILLNESS: 79-year-old white female with a
history of chronic obstructive pulmonary disease DISEASE
hypertension DISEASE paroxysmal atrial fibrillation DISEASE presents from
rehabilitation facility following an episode of tachypnea DISEASE
hypoxia DISEASE and obtundation DISEASE requiring endotracheal intubation.
The patient is status post a recent prolonged hospitalization
from [**7-4**] to [**7-25**] for gallstone pancreatitis DISEASE requiring
open cholecystectomy and choledochoduodenostomy on [**7-3**] by
Dr. [**Last Name (STitle) 1305**] with a long hospitalization complicated by E. coli
sepsis DISEASE a lower gastrointestinal bleed DISEASE with negative
colonoscopy volume overload DISEASE and a postoperative abdominal abscess DISEASE culture positive for vancomycin-resistant DISEASE
enterococcus requiring CT-guided drainage. The patient also
suffered C. difficile colitis DISEASE during this admission. Toward
the end of her hospitalization the patient was noted to have
acute tachypnea DISEASE pH 7.27 CO2 70 which resolved with minimal
intervention the following day. The patient was discharged
to a skilled nursing facility on [**7-25**] on a plan for
linezolid for four weeks for her VRE abscess DISEASE and Flagyl for
two weeks for her C. difficile colitis DISEASE .

At the skilled nursing facility the patient has done poorly
with continued lethargy anorexia DISEASE and depression DISEASE . She was
noted to have decreased sodium to 119 on [**8-3**] which was
question of serum-inappropriate antidiuretic hormone. The
patient developed cough DISEASE on [**7-29**] for which she was started
on Robitussin DISEASE and yesterday she was noted to have hypoxia DISEASE
with an oxygen saturation of 93% on 2 liters nasal cannula.
This morning shortly after breakfast the patient was noted
to become more tachypneic DISEASE and somnolent having an oxygen
saturation in the 60s on 2 liters improving to 97% on 100%
non-rebreather. She became increasingly somnolent and
became completely unresponsive. The patient was bag mask
ventilated and referred to [**Hospital1 188**] for further evaluation.

In the Emergency Department she was afebrile with heart
rate in the 80s blood pressure 140/80 oxygen saturation 90%
on 100% non-rebreather. She was unresponsive to voice and
pain DISEASE . The patient was subsequently intubated with
improvement in her mental status following intubation. A CTA
of the chest was performed without evidence of pulmonary
embolism DISEASE with scattered ground-glass opacities DISEASE slightly
increased right greater than left. Electrocardiogram was
without significant change. A head CT was negative for acute
bleed DISEASE or cerebrovascular accident DISEASE . After receiving 4 liters
of normal saline ceftriaxone Flagyl and lasix the patient
was transferred to the Intensive Care Unit.

Upon arrival to the Intensive Care Unit the patient spiked a
temperature to 101 and dropped her systolic blood pressure
from 130s to the 80s. The patient received a 1 liter fluid
bolus without significant change. She was subsequently
started on dopamine.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE
2. Chronic obstructive pulmonary disease DISEASE FEV-1 1.74 in [**2176**]
3. Atrial fibrillation DISEASE
4. Congestive heart failure DISEASE with an ejection fraction of
60% basal septal hypertrophy DISEASE 1 to 2Admission Date: [**2198-11-23**] Discharge Date: [**2198-11-27**]

Date of Birth: [**2135-1-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 45**]
Chief Complaint:
PEA arrest DISEASE
.


Major Surgical or Invasive Procedure:
temporary pacemaker placement
permanent Pacemaker placement [**2198-11-26**]


History of Present Illness:
Pt was in USOH awaiting R THR collapsed while celebrating a
funeral mass was down for 1 min prior to EMS arrival found to
be pulseless DISEASE atrial activity noted on stips but only occasional
wide qrs complexes could not transcut pace got atropine and
calcium gluc went to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **] was intubated for protection K
6.6 HCO3 13 and Cr 2.7. Got kayexylate bicarb gtt lasix and
extubated. ECG w/RBBB LAD LAFB and sig PR delay so sent here
for pacer. R IJ pacer wire screwed in but still temporary.
Transferred to [**Hospital1 18**] for permanent pacer and further managment.

Past Medical History:
PMH: HTN dyslipidemia DISEASE CRI (not formally dx per pt) OA w/ hip
pain DISEASE awaiting R THR h/o chronic low potassium and severe HTN DISEASE
per pt
-baseline trifasicular block

Social History:
Pt is a priest


Family History:
non-contributory

Physical Exam:
t 98.9
BP 131/79
HR 64
Tele: v-paced/ few PVC's with compensatory pauses
O2 sat 92%RA
Gen: elder male lying in bed NAD
HEENT: JVP flat MMM PERRLA EOMI
Heart: s1 s2 RRR. no MRG
Lungs: bibasilar crackles otherwise CTAB
Ext: 1Admission Date: [**2183-8-6**] Discharge Date: [**2183-9-15**]


Service:

PRIMARY DIAGNOSIS:
1. Volume overload anasarca DISEASE .
2. Status post posterior trach perforation DISEASE and repair.
3. Respiratory failure DISEASE with ventilatory dependence DISEASE .
Mechanical ventilatory dependence DISEASE .
4. Atrial fibrillation DISEASE .
5. Clostridium difficile infection DISEASE .
6. Malnourishment.
7. Sepsis. Status post treatment and resolution.
8. Pneumonia ventilatory associated status post
resolution and treatment.
9. Anemia.
10. Pleural effusions DISEASE .
11. Goiter DISEASE .
12. Hypothyroidism DISEASE
13. Urinary tract infection DISEASE numerous including pseudomonas.
14. Questionable myopathy DISEASE .
15. Yeast infection DISEASE of the urinary tract.
16. Thrombocytopenia DISEASE subsequent resolution.
17. Right internal jugular non-occlusive clot.
18. Hyponatremia DISEASE subsequently resolved.
19. Tracheostomy.
20. Hypothyroidism DISEASE .
21. Gastroesophageal reflux disease DISEASE .

SECONDARY DIAGNOSIS:
1. Status post cholecystectomy and choledochoduodenostomy.
2. Vancomycin resistant enterococcus bacteremia DISEASE in abscess.
3. History of lower gastrointestinal bleed DISEASE .

HISTORY OF PRESENT ILLNESS: Mrs. [**Known firstname **] [**Known lastname 5579**] is a
79-year-old female with chronic obstructive pulmonary DISEASE
disease hypertension DISEASE paroxysmal atrial fibrillation DISEASE who
presents from Shore House Rehabilitation following episodes
of tachypnea hypoxemia DISEASE and obtundation DISEASE requiring
endotracheal intubation. The patient is status post recent
hospitalization from [**7-4**] to [**2183-7-25**] for gallstone DISEASE
pancreatitis DISEASE requiring open cholecystectomy and
choledochoduodenostomy on [**2183-7-11**] by Dr. [**Last Name (STitle) 1305**] with
hospitalization complicated by E. coli sepsis DISEASE volume
overload DISEASE and bilateral pleural effusion atrial fibrillation DISEASE
and postop abdominal abscess DISEASE which grew out Vancomycin
Resistant Enterococcus.

The patient subsequently had a gallbladder drainage by CT
guidance on [**2183-7-18**]. The patient suffered C. diff colitis DISEASE at
prior hospitalization. Towards the end of hospitalization
was noted to have acute tachypnea DISEASE . She was subsequently
discharged to Shore House on [**2183-7-25**] on antibiotics
Linezolide for four week course for her Vancomycin resistant
enterococcus abscess DISEASE and Flagyl for 14 day course for C. diff
colitis DISEASE .

At the Shore House however the patient was doing poorly with
continued lethargy anorexia DISEASE and depression DISEASE . The patient was
noted to develop hyponatremia DISEASE . She apparently developed
cough DISEASE on [**7-29**] for which she was treated with Robitussin DISEASE and
the day prior to admission was noted to have hypoxemia DISEASE with
O2 saturations 90% on two liters nasal cannula.

On the morning of presentation to [**Hospital1 190**] the patient shortly was noted to become more
tachypneic DISEASE and somnolent with oxygen saturation in the 60's
and requiring 100% non-rebreather. The patient subsequently
then became unresponsive and was subsequently started manual
artificial respirations and was sent to [**Hospital1 190**] for further evaluation.

In the Emergency Room she was afebrile heart rate in the 80s
and blood pressure 140/80 oxygen saturation 90% on 100%
non-rebreather unresponsive. The patient subsequently
intubated at the Emergency Room at [**Hospital1 190**]. She was admitted to the Intensive Care Unit
for further treatment.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE .
2. Gastroesophageal reflux disease DISEASE FEV 1 of 1.74 70%
predicted.
3. Atrial fibrillation DISEASE .
4. Congestive heart failure DISEASE with ejection fraction of
60% Basal septal hypokinesis.
5. History of Gastrointestinal bleed DISEASE secondary to aspirin.
6. Degenerative joint disease.
7. Migraine headaches DISEASE .
8. Cataracts.
9. Substernal goiter DISEASE with hypothyroidism DISEASE status post
biopsy.

ALLERGIES: Aspirin which causes gastrointestinal bleed DISEASE .

MEDICATIONS ON PRESENTATION:
1. Linezolide 200 mg p.o. b.i.d.
2. Flagyl 500 mg p.o. q 8 hours.
3. Percocet
4. Atenolol 100 mg q day.
5. Ranitidine 150 mg p.o. q day.
6. Levoxyl 75 mcg q day.
7. Lasix 40 mg p.o. q day.
8. Amiodarone 200 mg p.o. q day.
9. Florinef 0.1 mg p.o. q day.
10. Prednisone 30 mg p.o. q day.

PHYSICAL EXAMINATION: Upon presentation the patient was
subsequently intubated temperature 101 heart rate 70 to 80
and atrial fibrillation DISEASE . Blood pressure 107/48 on Dopamine.
Skin was dry. Head eyes ears nose and throat:
Normocephalic atraumatic. Pupils are equal round and
reactive to light and accommodation. Oropharynx dry DISEASE . Neck:
Prominent external jugular veins. Lungs: Bilaterally coarse
breath sounds. Cardiac: Irregular rate and rhythm no
murmurs rubs or gallops. Abdomen: Surgical site healing
well. Hyperactive bowel sounds soft DISEASE nontender to
palpation. Extremities: No edema DISEASE peripheral pulses 2Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]

Date of Birth: 04/[**Numeric Identifier 5590**] Sex: F

Service: [**Hospital **] MEDICAL INTENSIVE CARE UNIT
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
female with multiple medical problems and a prolonged recent
Intensive Care Unit stay. She was readmitted with prepped
and draped. In [**Month (only) **] of this year she had gallstone DISEASE
pancreatitis DISEASE requiring open cholecystectomy and her course
congestive heart failure atrial fibrillation DISEASE C-diff
respiratory failure DISEASE followed by failure DISEASE to wean and because
of this she had a tracheostomy the placement of which was
complicated by tracheal tear requiring placement of a
specialized trachea and urgent repair. Additionally she has
an unclear myopathic neuropathic DISEASE process resulting in
generalized total body weakness. She was sent to [**Location (un) 511**]
admission after respiratory distress DISEASE and reported granulation DISEASE
tissue in her tracheal site. Plans were made for a
bronchoscopy in the morning. She denied shortness of breath DISEASE
chest pain DISEASE or cough DISEASE .

PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial
fibrillation DISEASE . 3. Vent dependent believed to be secondary to
myopathy neuropathy DISEASE . 4. Recent C-diff. 5. Volume
overload DISEASE . 6. Malnutrition. 7. Status post tracheal
perforation DISEASE . 8. Goiter hypothyroid DISEASE . 9. Right IJ clot.
10. Gastroesophageal reflux disease DISEASE . 11. Status post
cholecystectomy. 12. Status post intra-abdominal abscess DISEASE .

ALLERGIES: ASPIRIN LEVOFLOXACIN VANCOMYCIN GENTAMICIN.

MEDICATIONS ON ADMISSION: Synthroid 75 q.d. Metoprolol 25
b.i.d. Prilosec 40 q.d. Flagyl 500 t.i.d. Paxil 20 q.d.
Vitamin C 500 b.i.d. Zinc 220 q.d. Trazodone 25 q.h.s.
Zofran p.r.n. Coumadin Lasix 20 q.d. Promote tube feeds 65
cc/hr.

PHYSICAL EXAMINATION: Vital signs: Pulse 100 blood
pressure 109/65 oxygen saturation 99% on room air. General:
She was an elderly white female in no acute distress. HEENT:
Unremarkable. Lungs: Coarse breath sounds throughout.
Cardiovascular: Irregularly irregular with normal S1 and
S2. Abdomen: Benign. Extremities: There was 3Admission Date: [**2103-10-7**] Discharge Date: [**2103-10-11**]

Date of Birth: [**2054-1-14**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old
woman with a negative past medical history who at 4:45 p.m.
on the day of admission complained of left-sided numbness DISEASE
and tingling. At 5:15 p.m. she noted right upper quadrant
numbness DISEASE . The patient picked up the phone and was unable to
hold on to the phone. She dropped the phone and then began
having difficulty walking. She was taken to [**Hospital3 3583**]
and she was unable to walk once she got to [**Hospital3 3583**].

She had a head CT of the brain which showed a 3.5-cm
right-sided mass with hyperintense ring enhancement and mild
edema DISEASE .

PAST MEDICAL HISTORY: Benign.

PAST SURGICAL HISTORY: Cesarean section 14 years ago and
varicose vein stripping.

ALLERGIES: SULFA to which she gets a rash DISEASE .

MEDICATIONS ON ADMISSION: No medications.

PHYSICAL EXAMINATION ON PRESENTATION: The patient had a
blood pressure of 131/69 temperature 98.4 heart rate 91
respiratory rate 11 to 18 saturation 97% to 98% on room air.




[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**] M.D. [**MD Number(1) 343**]

Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36

D: [**2103-10-11**] 15:20
T: [**2103-10-11**] 14:26
JOB#: [**Job Number 5605 DISEASE **]

(cclist)
Admission Date: [**2191-5-9**] Discharge Date: [**2191-5-13**]

Date of Birth: [**2120-12-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Chief Complaint: LLE pain DISEASE and SOB

Reason for MICU transfer: close hemodynamic monitoring


Major Surgical or Invasive Procedure:
none


History of Present Illness:
The patient is a 70 yo M with a hx of PE/DVT DISEASE [**8-23**] whose
anticoagulation was recently stopped [**3-30**] after a neg CTA and
negative doppler study who now presents with recurrent DVT/PE DISEASE .
He reports experiencing left sided lower extremity edema DISEASE that
has been present since his initial DVT DISEASE presentation [**8-23**]. This
became significantly work for the past 2 days along with left
foot pain DISEASE . He presented to [**Hospital3 **] where he was
found to have an extensive DVT DISEASE in the LLE and was given a dose
of lovenox 100 mg at 0220 and coumadin 10 mg at 0200. He also
reportedly endorsed some discomfort and a CTA revealed a saddle
PE. He was subsequently transferred to [**Hospital1 18**] for further
management. Pt reports he is only minimally ambulatory due to
Admission Date: [**2105-11-10**] Discharge Date: [**2105-11-15**]

Date of Birth: [**2049-2-26**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Quinine / Vicodin

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Sepsis/confusion

Major Surgical or Invasive Procedure:
R groin and L IJ central lines R wrist and L groin arterial
lines

History of Present Illness:
56 yo m transferred from [**Hospital **] hospital w/ end stage liver dz
[**3-6**] hepatitis sclerosing cholangitis UC DISEASE on the transplant
list and normally followed at [**Hospital1 336**] (no beds available) who
presented from OSH septic DISEASE on peripheral pressors. He had been in
rehab x 3 months more recently had failure DISEASE to thrive. Today
presents to [**Hospital1 **] ER with a BP 82/39 HR 45 WBC 18
creatinine 4.4 Bili 24. Given daptomycin and imipenem at OSH.
.
In the ED vitals were t 90 hr 50 bp 82/40 sat 98% ra. Noted
to have a lactate of 12.2 and an ABG 7.04/19/122. Patient given
daptomycin and imipenem for broad coverage. R IJ attempted but
failed. L femoral line placed. Was intubated for airway
protection requiring minimal sedation given underlying
encephalopathy DISEASE . Was started on levophed for BP support. On
placement of OGT noted to have Admission Date: [**2132-3-11**] Discharge Date: [**2132-4-2**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
abnormal CXR anemia DISEASE

Major Surgical or Invasive Procedure:
intubation
central line placement
bronchoscopy
arterial line placement

History of Present Illness:
The patient is an 84M with prostate CA DISEASE CAD HTN DISEASE who presents
with 2 weeks dry cough DISEASE . He saw his hematologist who ordered a
CXR for the cough DISEASE and it showed extensive heterogenous
opacification in the right lung. Because of these abnormal
findings his PCP told him to come to the ED for evaluation.

He has had the intermittent dry cough DISEASE for about two weeks but
has not had fevers chills DISEASE weight loss DISEASE change in appetite shortness of breath nausea vomiting diarrhea DISEASE . He has noticed
some fatigue DISEASE as he used to walk two miles a day until the cough DISEASE
started but notes he is limited by fatigue DISEASE not DOE. No other
symptoms. In the ED he was noted to have a dropping Hct (25.4
down from 29.6 the previous day). He has not noted blood in his
stool or had any lightheadedness. He was guaiac negative. He was
being worked up for anemia DISEASE and was not found to have evidence of
iron folate or B12 deficiency DISEASE in [**2-4**]. SPEP was also normal.
After discussion with his PCP by the [**Name9 (PRE) **] he is being admitted
for expedited workup of CXR findings and anemia DISEASE . Pulmonology was
consulted in the ED.

ROS:
-Constitutional: []WNL [] Weight loss DISEASE [x]Fatigue/Malaise []Fever
[] Chills/Rigors DISEASE []Nightsweats []Anorexia
-Eyes: [x]WNL []Blurry Vision [] Diplopia DISEASE []Loss of Vision
[]Photophobia
-ENT: []WNL [x]Dry Mouth []Oral ulcers DISEASE []Bleeding gums/nose
[]Tinnitus [] Sinus pain DISEASE []Sore throat
-Cardiac: [x]WNL [] Chest pain DISEASE []Palpitations []LE edema DISEASE
[]Orthopnea/PND []DOE
-Respiratory: []WNL []SOB []Pleuritic pain DISEASE [] Hemoptysis DISEASE [x]Cough
-Gastrointestinal: [x]WNL [] Nausea DISEASE []Vomiting []Abdominal pain
[]Abdominal Swelling [] Diarrhea DISEASE [] Constipation DISEASE []Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [x]WNL []Bleeding [] Bruising DISEASE [] Lymphadenopathy DISEASE
-GU: [x]WNL []Incontinence/Retention []Dysuria [] Hematuria DISEASE
[]Discharge []Menorrhagia
-Skin: [x]WNL [] Rash DISEASE [] Pruritus DISEASE
-Endocrine: [x]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance -Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain DISEASE
-Neurological: [] Numbness of extremities []Weakness DISEASE of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache
-Psychiatric: [x]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [x] WNL []Seasonal Allergies


Past Medical History:
prostate cancer DISEASE diagnosed [**2130**] getting treated with hormonal
therapy followed by Dr. [**Last Name (STitle) 365**]
CAD s/p CABG [**2112**]
dyslipidemia DISEASE
HTN DISEASE
NSVT DISEASE SSS s/p ICD/PM
severe left ventricular dysfunction DISEASE (EF 20% in [**2-3**])


Social History:
He lives in [**Hospital3 **] with his wife. [**Name (NI) **] has a son who has had
multiple bypass surgeries and significant cardiac disease DISEASE . He
had a daughter who passed away from cancer DISEASE . He has no smoking
history. Reports drinking alcohol drinking one glass of
alcohol every night prior to dinner. He is retired.


Family History:
Son w/ multiple CABGs
daughter w/ cancer DISEASE

Physical Exam:
Physical Exam:
Appearance: NAD
Vitals: T: 96.4 BP: 124/59 HR: 71 RR: 20 O2: 100% 2L
Eyes: EOMI PERRL conjunctiva clear noninjected anicteric no
exudate DISEASE
ENT: Moist
Neck: No JVD no LAD no thyromegaly no carotid bruits DISEASE
Cardiovascular: RRR nl S1/S2 no m/r/g
Respiratory: exam limited by coughing poor air movement
diffusely wheezy DISEASE
Gastrointestinal: soft non-tender non-distended no
hepatosplenomegaly DISEASE normal bowel sounds
Musculoskeletal/Extremities: no clubbing no cyanosis DISEASE no joint
swelling DISEASE no edema DISEASE in the bilateral extremities
Neurological: Alert and oriented x3 fluent speech no pronator
drift no asterixis DISEASE sensation WNL CNII-XII intact strength
[**4-1**] in upper and lower extremities bilaterally
Integument: warm no rash DISEASE no ulcer DISEASE
Psychiatric DISEASE : appropriate pleasant
Hematological/Lymphatic: No cervical lymphadenopathy DISEASE


Pertinent Results:
[**2132-3-11**] 11:15AM GLUCOSE-116* UREA N-23* CREAT-1.1 SODIUM-133
POTASSIUM-4.4 CHLORIDE-98 DISEASE TOTAL CO2-26 ANION GAP-13
[**2132-3-11**] 11:15AM CK(CPK)-117
[**2132-3-11**] 11:15AM CK-MB-4
[**2132-3-11**] 11:30AM cTropnT-0.01
[**2132-3-11**] 11:15AM WBC-7.9 RBC-2.85* HGB-8.5* HCT-25.4* MCV-89
MCH-29.9 MCHC-33.6 RDW-13.9
[**2132-3-11**] 11:15AM PLT COUNT-274
[**2132-3-10**] 10:10AM LD(LDH)-259* TOT BILI-0.5 DIR BILI-0.2 INDIR
BIL-0.3
[**2132-3-10**] 10:10AM HAPTOGLOB-492*
[**2132-3-10**] 10:10AM IgG-1510 IgA-278 IgM-58
[**2132-3-10**] 10:10AM RET AUT-1.3
[**2132-3-10**] 09:45AM WBC-7.9 RBC-3.34* HGB-10.0* HCT-29.6* MCV-89
MCH-29.9 MCHC-33.7 RDW-14.2
[**2132-3-10**] 09:45AM NEUTS-74.5* LYMPHS-11.7* MONOS-4.7 EOS-9.0*
BASOS-0.2
[**2132-3-10**] 09:45AM PLT COUNT-266#
[**2132-3-11**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2132-3-11**] 03:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2132-3-11**] 03:30PM URINE RBC-0-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0-2

[**3-10**] PA AND LATERAL CHEST RADIOGRAPH:
Multiple midline sternotomy wires are unchanged in position.
Small surgical clips are seen along the left cardiac border
compatible with prior CABG. The two-chamber pacemaker with ICD
is seen with leads in the right ventricle and right atrium
unchanged. There is mild cardiomegaly DISEASE . The mediastinal and hilar
contours are unchanged. Pulmonary vasculature is unremarkable.
There is no pneumothorax DISEASE or large pleural effusion DISEASE .

New extensive heterogeneous opacification is seen
predominately in the right lung with peripheral consolidation
and lesser degree of central opacification. Right- sided volume
loss suggests a chronic process. Left basilar opacities DISEASE are
compatible with atelectasis DISEASE and the left lung is otherwise
clear.

IMPRESSION:
Compared to [**2124**] study new extensive heterogeneous
opacification in the right lung with peripheral consolidation
and lesser degree of central opacification. Loss of right lung DISEASE
volume suggests a subacute process. Differential is broad
including pneumonia postinfectious DISEASE and cryptogenic organizing
pneumonia DISEASE multifocal bronchioloalveolar cell carcinoma DISEASE chronic
eosinophilic pneumonia DISEASE Churg- [**Doctor Last Name 3532**] vasculitis amiodarone
toxicity DISEASE .

[**3-11**] CXR:
No interval change over one day in appearance of diffuse
airspace opacity DISEASE involving the right hemithorax. Additional
opacity DISEASE seen in the left base also unchanged. Original
differential diagnosis stands and multifocal pneumonia DISEASE cannot be
excluded.

CT CHEST: FINDINGS
The patient is intubated. Pooling of secretions are above the
cuff of the
endotracheal tube. Small layering bilateral non-hemorrhagic
pleural effusions DISEASE
are increased on the right and new on the left. Diffuse
extensive areas of
ground-glass opacity DISEASE peribronchial consolidation and
bronchiectasis DISEASE have
worsened in the left lung minimally improved in the right upper
lobe. Right
central catheter tip is in the mid SVC. Transvenous pacemaker
lead terminates
in a standard position. NG tube tip is out of view below the
diaphragm. Dense
calcifications DISEASE are in the native coronary arteries. There is
mild-to-moderate
cardiomegaly DISEASE . The cardiac [**Doctor Last Name 1754**] are hypodense. This suggests
anemia DISEASE .
Calcification DISEASE in the aortic valve is of unknown hemodynamic
significance. AP
window and prevascular lymph nodes have increased in sizeAdmission Date: [**2170-3-6**] Discharge Date: [**2170-3-14**]

Date of Birth: [**2140-8-29**] Sex: F

Service: Medicine

HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old
female with end-stage renal disease DISEASE on hemodialysis who was
admitted to the Medical Intensive Care Unit from the
Emergency Department with sepsis DISEASE . The patient was in her
usual state of health until after her usual Monday
hemodialysis session. The session lasted three hours and was
complicated by line thrombosis DISEASE .

Upon arriving home she felt profoundly fatigued was
vertiginous DISEASE and had diffuse long bone pain DISEASE felt febrile DISEASE
and was nauseated and vomited once. She also noted mild
shortness of breath DISEASE with mild pleuritic chest pain DISEASE . The
patient took Tylenol with no relief.

On the morning of [**3-6**] she presented to the
Emergency Department and was found to have a blood pressure
of 90/60 which was responsive to 1 liter of normal saline.
The patient had generalized weakness DISEASE and mild abdominal pain DISEASE .
A left external jugular central line was attempted but
became infiltrated and was removed with resulting hematoma DISEASE .
A successful right femoral line was then placed. Her
temperature was 101 with a white blood cell count of 35.8.
She was transiently hypoxic briefly requiring a face mask to
sustain an oxygen saturation of greater than 90%. She was
also found to have a potassium of 9.2. She was given insulin
D50 calcium gluconate and bicarbonate. An EKG showed
peaked T waves with widening of the QRS intervals. Patient
was taken for hemodialysis during which time blood cultures
were drawn and Vancomycin was given empirically.

REVIEW OF SYSTEMS: Diarrhea. Patient traveled to [**State 108**]
nausea weakness DISEASE mild headache DISEASE mild photophobia DISEASE . Patient
has gained 30 pounds and lost 30 pounds over the past year.
Patient denied shortness of breath chest pain dysuria DISEASE neck
stiffness abdominal pain DISEASE sick contacts vision changes and
leg pain DISEASE .

PAST MEDICAL HISTORY:
1. End-stage renal disease DISEASE secondary to IgA nephropathy DISEASE
diagnosed 12 years ago. Patient has been on hemodialysis
since [**2164**] status post multiple A-V graft revisions.
2. Right Permacath for the past four months status post trial
of peritoneal dialysis. Patient is on the renal transplant
list.
3. Hypertension DISEASE .
4. Major depressive disorder DISEASE on Zoloft and Seroquel.
5. Pseudotumor cerebri DISEASE in [**2164**].
6. Positive PPD status post INH in [**2156**].
7. Left ovarian cyst DISEASE removal.
8. Hyperkalemia DISEASE status post A-V graft thrombus DISEASE in [**2169-3-4**].

MEDICATIONS:
1. Renagel t.i.d.
2. Nephrocaps q.d.
3. Sertraline 150 mg p.o. q.h.s.
4. Atenolol 25 mg p.o. b.i.d.
5. Zestril 5 mg p.o. b.i.d.
6. Epogen with hemodialysis.
7. Seroquel 100 mg p.o. q.d.

ALLERGIES: Patient has a questionable allergy DISEASE to Vancomycin
which causes pruritus DISEASE .

SOCIAL HISTORY: The patient lives with her mother and
sister. She works as a cytotechnologist. She denies
smoking. She has limited alcohol use and she denies any
drug use.

FAMILY HISTORY: No significant family history.

PHYSICAL EXAM DISEASE ON ADMISSION: Temperature was 101.0 blood
pressure 156/104 heart rate 101 respiratory rate 22 and
oxygen saturation 98% on 2 liters. In general the patient
was alert and oriented times three in no acute distress.
HEENT: Facial rash DISEASE consistent with acne DISEASE . Pupils are equal
round and reactive to light. Extraocular muscles are
intact. Visual fields were full bilaterally. Conjunctivae
were injected diffusely on the right. Oropharynx showed no
lesions. Neck was supple without bruits masses or
thyromegaly. There was no lymphadenopathy DISEASE . Cardiovascular:
Nondisplaced PMI S1 greater than S2 no murmurs rubs or
gallops. Pulmonary: Clear to auscultation bilaterally no
wheezes or egophony. Abdomen: Normoactive bowel sounds
soft nontender nondistended no hepatosplenomegaly DISEASE no
masses and no bruits. Groin: Right femoral line clean
dry DISEASE and intact. Extremities: No clubbing cyanosis DISEASE or
edema DISEASE . 2Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]


Service:

DISCHARGE DIAGNOSES:
1. Ventilatory dependence.
2. Atrial fibrillation DISEASE .
3. Neuropathy and weakness DISEASE .
4. Hyperthyroidism.
5. Gastroesophageal reflux disease DISEASE .
6. Status post gallbladder removal.

KNOWN ALLERGIES AT THE TIME OF DISCHARGE: 1. Levofloxacin
causes a rash DISEASE . 2. Vancomycin causes hearing loss DISEASE . 3.
Aspirin Celebrex and non-steroidal anti-inflammatory drugs
the patient cannot tolerate. 4. Gentamycin cannot tolerate
per the patient's son.

MEDICATIONS ON DISCHARGE: 1. Vitamin C 500 q.d. 2. Paxil
40 mg q.h.s. 3. Bactrim double strength one tab b.i.d.
until [**2183-10-21**]. 4. Prednisone 60 mg q.d. until
[**2183-11-4**] per neurology request. 5. Coumadin 3 mg po
q.h.s. adjust to goal INR of 2.0 to 3.0. 6. Regular insulin
per sliding scale. 7. Captopril 37.5 mg t.i.d. 8. Colace
100 b.i.d. 9. Prevacid 30 mg q.d. 10. Senna two tabs
b.i.d. 11. Digoxin 0.125 mg q.d. 12. Synthroid 75
micrograms q.d. 13. Trazodone 25 mg q.h.s. prn for sleep.

NUTRITIONAL NEEDS: The patient is lactose intolerant.

VENTILATORY SETTINGS: Mrs. [**Known lastname 5579**] has been attempted to
use a Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]


Service:

HISTORY OF PRESENT ILLNESS: The following discharge summary
will cover the time period from [**10-15**] through [**2183-10-28**].
Please see previous discharge summary for information on
patient's admission diagnosis and medications.

HOSPITAL COURSE:
1. Gastrointestinal. On [**10-16**] the patient developed nausea vomiting DISEASE and abdominal pain DISEASE . Because of this she was not
discharged to rehabilitation at [**Location (un) 511**] Center Hospital
as had been previously planned. Due to her symptoms a CT
scan was obtained which revealed the patient had an ileus DISEASE .
There were no abscesses or other processes that could be
identified. The neurology service was consulted regarding
possibility of this ileus DISEASE being related to the patient's
myopathy DISEASE but felt this was unlikely since skeletal muscle
myopathies typically do not also involve smooth muscle of the
Gastrointestinal tract. A Gastrointestinal consult was
obtained who had no additional thoughts on what could be
causing the patient's ileus DISEASE and recommended bowel rest. The
patient was kept off tube feeds for two days after which time
they were restarted at a low rate of 20 cc's an hour as
compared to her goal rate of 65 cc's per hour. The patient
appeared to tolerate this reasonably well and the tube feeds
were increased. When they reached the rate of 30 cc's an
hour however the patient developed nausea DISEASE and vomiting DISEASE a
second time. Tube feeds were again stopped and her bowel was
rested for several days.

On [**10-24**] it was decided that because the patient was unable
to tolerate tube feeds at a reasonable rate she would be
started on TPN for nutrition. At the time of this dictation
on [**10-27**] the patient was reporting decreased abdominal pain DISEASE
and no further nausea DISEASE or vomiting. She additionally had been
successful in moving her bowels and treated with Colace
Senokot and Fleet enemas. The suspicion of the team at this
point in time is that her ileus DISEASE is resolving however very
slowly. Her tube feeds will need to be started at a very
slow rate advanced extremely gently as tolerated with
caution being taken because when the rate is increased to
abruptly she does tend to develop nausea DISEASE and vomiting DISEASE . She
will be discharged out on no tube feeds they can be started
when she arrives at [**Location (un) 511**] Center for rehabilitation.
She will be discharged out on TPN which she can continue.
Additionally we will maintain her on [**Doctor Last Name **] and Colace.

2. Pulmonary. The patient continued to do well on a trach
mask and in fact tolerated trach mask ventilation for five
days in a row with no support from mechanical ventilator.
Because of this she was deemed safe to go to the floor
something which the team and the patient's family were very
happy with as it was thought this could be a trial
preliminary to transferring her to rehabilitation home. On
[**10-21**] she was transferred to the floor. Unfortunately however
on [**10-22**] she was found to be hypoxic to the low 80's on the
floor. She was suctioned with thick tenacious dark
secretions came out her O2 sats increased to the mid-80's.
Chest x-ray was consistent with a left sided opacity DISEASE
throughout which was new. She was transferred back to the
Intensive Care Unit with ventilatory support and bronchoscopy
was performed which revealed purulent drainage from the left
mainstem sample was sent. Chest x-ray after bronchoscopy
revealed markedly improved air space. O2 saturations
increased to 98% on only .4 FIO2. Following this episode the
patient was rested in IMV for several days. At the time of
this admission she was feeling better and feeling strong
enough to try pressor support ventilation again.

The teams thinking is that perhaps the patient needs to be
rested each night in an MV mode letting her use only a trach
mask for five days may have been to much to soon and in the
future we will get her to tolerate pressor support and rest
her on the night and possibly during the day allowing her to
breath through the trach mask. Currently she is being
weaned this will need to be continued at [**Hospital1 **].

Per discussion with the family the pulmonary attending is
planning to call the pulmonary attending at [**Hospital1 **]
to communicate the patient's need regarding ventilatory
management.

3. Infectious disease. On [**10-16**] the patient's urine grew out
Enterobacter which was sensitive only to Mirpenum and one
other [**Doctor Last Name 360**]. She was treated with Mirpenum for seven days.
At approximate completion of the 7 days course the patient's
BAL sample from her bronch grew out pseudomonas which was
resistant to Mirpenum. Because of this switched to Zosyn
which the pseudomonas was sensitive to. She will be
discharged on this and need to complete a 10 to 14 day
course. Additionally she was started on Flagyl for possible
C. diff given that she was complaining of abdominal pain DISEASE and
was feeling extremely weak. Of note she did not have
diarrhea DISEASE . She did seem to get better after starting the
Flagyl so she will need to complete a 14 day course of this
as well for empiric therapy for C. diff.

Also of note the patient had one set of blood cultures
positive for coag negative staph however it was deemed that
this was a contaminant and the decision was made not to treat
after consultation with Infectious Disease DISEASE service.

4. Neurological. The patient continued to show improvement
in her strength while on 60 mg of Prednisone a day. The
original plan had been for her to be treated for 4 weeks with
60 mg of Prednisone empirically and then follow-up with the
neuromuscular service for a decision as to whether or not to
continue this. However after approximately 2-1/2 weeks of
therapy the patient had issues with infectious disease DISEASE as
detailed above including urinary tract infection DISEASE and
pulmonary infection DISEASE . Because of these issues with highly
resistant bacteria it was deemed that the best thing to do
would be to taper the steroids.

On approximately [**10-22**] the patient was cut from 60 to 40 mg of
Prednisone a day and on [**10-27**] the day of this dictation the
patient was cut to 20 mg a day. She will need to continue
this slow taper until the steroids had been weaned to off.
If her improvement in neurologic function continues even off
the steroids then she can probably never start on steroids
again however if she shows a decline once she is off
steroids this will further enforce the theory that the
steroids are what has been treating her myopathy DISEASE and once she
is clear for infectious DISEASE issues she should be restarted on
steroids in the future. She will follow-up with the
neuromuscular service as detailed in her previous discharge
summary.

5. Psychiatric. On one occasion the patient during the
night the patient became quite despondent and request that
she did not wish to continue with this therapy as she was
incredibly frustrated. However the team had multiple
discussions on their rounds and at the time of this dictation
the patient's mood had significantly improved and her will to
fight on actually seemed quite remarkable. She is continued
on her Paxil and at the present time the team did not see any
need for additional psychiatric DISEASE intervention.

6. Communication. A family meeting was held on [**2183-10-27**]
with the patient's two daughters son and husband as well as
the attending physician in the Intensive Care Unit Dr. [**First Name (STitle) **]
Dr. [**First Name (STitle) **] the former Intensive Care Unit attending myself
Dr. [**First Name (STitle) 916**] and the patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Discussion was held
as to the patient's status. We discussed the fact that the
family had previously wished for the patient to have
resolution of all her issues prior to going to
rehabilitation. However we explained that her issues seemed
to be taking quite sometime the resolve and that we will have
to accept the fact that her issues are stable and improving
although not completely resolved. Additionally was discussed
the fact that the patient was clearly ready for
rehabilitation now and likely many of her problems including
her pulmonary and gastrointestinal problems DISEASE may benefit from
getting her out of bed and having her go to rehabilitation.
The family was open to this and grateful for our assistance.
Tentative plans were made to arrange for discharge to [**Hospital1 5593**] on [**2183-10-29**].

An addendum to this discharge summary will be dictated
following this detailing the events of the 15th and 16th.
Please refer to that discharge summary for the exact meds at
discharge and discharge diagnosis.

DIAGNOSIS AT TIME OF THIS DICTATION:
1. Respiratory failure DISEASE resulting in ventilatory dependence DISEASE .
2. Myopathy DISEASE of unclear etiology.
3. Ileus DISEASE of unclear etiology.
4. Pseudomonas pneumonia DISEASE .
5. Enterobacter urinary tract infection DISEASE .






[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] M.D. [**MD Number(1) 292**]

Dictated By:[**Last Name (NamePattern1) 1213**]
MEDQUIST36

D: [**2183-10-27**] 20:51
T: [**2183-10-27**] 21:10
JOB#: [**Job Number 5594**]
Admission Date: [**2184-1-16**] Discharge Date: [**2184-1-20**]


Service: [**Hospital1 212**]

HISTORY OF PRESENT ILLNESS: This 79-year-old woman is
admitted for respiratory distress hyponatremia DISEASE and
hyperkalemia DISEASE . This woman has had a complicated medical
course over the past six months which has included several
episodes of respiratory failure DISEASE difficulty to wean off a
ventilator tracheostomy placement complicated by tracheal
tear (requiring open sternotomy) anasarca DISEASE atrial
fibrillation E.coli sepsis DISEASE pseudomonas urinary tract
infection VRE intraabdominal abscess DISEASE and Clostridium DISEASE
difficile colitis DISEASE . Her ventilatory difficulties DISEASE were thought
to be perhaps secondary to a myopathic process although
muscle biopsy results were inconclusive and not demonstrative
of inflammatory changes.

Patient was admitted to [**Hospital1 **] [**10-28**]
through [**2183-12-18**] and successfully weaned from the
ventilator there. She was transferred to [**Hospital1 5595**] [**2183-12-18**] where she was gradually reintroduced to p.o. feed and
weaned from PEG feeds. She currently tolerates a pureed
diet. Her atrial fibrillation DISEASE has been managed via rate
control as the Amiodarone she was previous on was felt to
possibly contribute to her myopathy DISEASE . She had been on Lasix
(40 mg b.i.d.) on transfer from [**Hospital1 **] and
nonetheless gained 12 pounds from [**12-28**] through
[**1-15**]. Lasix was decreased to 20 mg q. day on [**1-12**] because her sodium was noted to be 129.

On [**1-15**] the patient was noted to have increased
dyspnea DISEASE and tachypnea DISEASE . She states she has had intermittent
dry cough DISEASE for several days. No subjective fevers or chills DISEASE .
She was transferred to [**Hospital1 69**]
today with still more dyspnea DISEASE / tachypnea sodium of 126 and
a potassium of 6.2.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE .
2. Atrial fibrillation DISEASE .
3. Diastolic dysfunction DISEASE (latest echo [**2183-9-30**] ejection
fraction of 70 to 80% (2Admission Date: [**2118-8-10**] Discharge Date: [**2118-8-12**]

Date of Birth: [**2073-12-25**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
elective admission for radionecrosis DISEASE resection due to
radiosurgery of AVM DISEASE

Major Surgical or Invasive Procedure:
Left craniotomy for radionecrosis DISEASE resection


History of Present Illness:
Presents for resection of radionecrosis DISEASE s/p radiosurgery for AVM DISEASE

Past Medical History:
seizuresh/o radio therapy for avm has resid edema DISEASE causing
seizuresAdmission Date: [**2190-5-16**] Discharge Date: [**2190-5-22**]

Date of Birth: [**2139-4-22**] Sex: F

Service: CARDIOTHORACIC

HISTORY OF PRESENT ILLNESS: This 51 year-old female was
admitted to an outside hospital with chest pain DISEASE and ruled in
for myocardial infarction DISEASE . She was transferred here for a
cardiac catheterization.

PAST MEDICAL HISTORY: Hypertension fibromyalgia DISEASE
hypothyroidism NASH DISEASE and noninsulin DISEASE dependent diabetes DISEASE .

PAST SURGICAL HISTORY: Hysterectomy and cholecystectomy.

SOCIAL HISTORY: She smokes a pack per day.

MEDICATIONS ON ADMISSION: Hydrochlorothiazide Alprazolam
Ursodiol and Levoxyl.

She was hospitalized with Aggrastat nitroglycerin and
heparin as she ruled in for myocardial infarction DISEASE .

ALLERGIES: No known drug allergies DISEASE .

Cardiac catheterization showed left anterior descending
coronary artery diagonal 80% lesion circumflex 90% lesion
and 90% lesion of the right coronary artery with a normal
ejection fraction. She was transferred from [**Hospital3 68**]
to [**Hospital1 69**] for cardiac
catheterization. The results as above. After
catheterization she was referred to cardiothoracic surgery
and was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] and Dr. [**First Name4 (NamePattern1) 71**] [**Last Name (NamePattern1) 72**].
Preoperative laboratories showed a sodium of 141 K 4.2
chloride 105 CO2 24 BUN 12 creatinine 0.6 with a blood
sugar of 156. White count 8.9 hematocrit 44.2 platelet
count 201000. PT 13 PTT 26 with an INR of 1.2. CK was
1511 on [**5-16**]. She was also followed by Dr. [**Last Name (STitle) 73**] of
cardiology and agreed to participate in both the Cariporide
and Dermabond studies through cardiac surgery. The patient
was taken to the Operating Room on [**5-18**] and underwent
coronary artery bypass grafting times four with a left
internal mammary coronary artery to the left anterior
descending coronary artery saphenous vein graft to right
posterior descending coronary artery saphenous vein graft to
diagonal two and a saphenous vein graft to the obtuse
marginal by Dr. [**Last Name (STitle) 70**].

The patient was transferred to the Cardiothoracic Intensive
Care Unit in stable condition. On postoperative day number
one there were no events overnight. The patient was
extubated and was on a neo-synephrine drip at 0.3 micrograms
per kilo per minute with the Cariporide infusing.
Nitroglycerin had been turned off. Postoperative hematocrit
was 30 with a K of 4.2 and a blood sugar of 139. CPK trended
down to 357 and 379 with an MB of 15 to 16. The patient was
in sinus rhythm in the 80s with a stable blood pressure. She
was alert and oriented. Her lungs were clear bilaterally.
Heart was regular rate and rhythm. Her abdomen was benign.
Her extremities were within normal limits. She was
neurologically stable. Her chest tubes were pulled on
postoperative day number three. She continued on
perioperative antibiotics and was transferred out to the
floor.

She was seen by physical therapy for evaluation. On
postoperative day two she had no events overnight. She had a
temperature max of 100.6. Her JP drain from her leg site was
removed as was her Foley. Her Lopresor was increased to 50
b.i.d. She began to ambulate and was out of bed. She had
decreased at the bases but was otherwise hemodynamically
stable. Her dressings were clean dry DISEASE and intact. She was
seen by case management to determine the need for rehab. Her
pacing wires were discontinued on postoperative day three.
She continued to advance her ambulation. She had decreased
breath sounds a the bases again on postoperative day three
but was stable and continuing to increase her physical
therapy. Her incision was were clean dry DISEASE and intact. Pain
was managed with Percocet and Motrin. She was sating 92% on
room air on postoperative day number four the day of
discharge with a temperature max of 99.3 blood pressure
136/71 heart rate 93. She was alert oriented and had been
ambulating well. Her lungs were clear bilaterally. Her
examination was otherwise benign.

Her laboratories on the 9th showed a white count of 13.6
hematocrit 28.7 platelet count 153000 BUN 15 creatinine
0.5 sodium 141 glucose 100 K 3.8 magnesium 1.7 for which
she received 2 grams of repletion. Calcium 1.08 for which
she received 2 grams of repletion. She was discharged to
home on postoperative day four [**5-22**].

DISCHARGE MEDICATIONS: Lasix 20 mg po q.d. times one week
K-Ciel 20 milliequivalents po q day times one week. Colace
100 mg po q.d. Zantac 150 mg po b.i.d. enteric coated
aspirin 325 mg po q day Levoxyl 0.25 mg po q day Lopressor
75 mg po b.i.d. Nicoderm 14 patch q.d. Xanax 2 mg q 4 to 6
hours prn Ursodiol dosage not specified. The patient was
instructed to return to preoperative dose. Percocet one to
two tabs po prn q 4 to 6 hours.

The patient was afebrile. Incisions were healing well.

DISCHARGE DIAGNOSES:
1. Hypertension DISEASE .
2. Status post coronary artery bypass grafting times four.
3. Fibromyalgia.
4. Hypothyroidism.
5. Noninsulin dependent diabetes mellitus DISEASE .
6. Question NASH DISEASE .

She was also instructed to follow up with her primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74**] in two weeks and follow up with Dr.
[**Last Name (STitle) 70**] in the office in six weeks for postop follow up.
Again the patient was discharged home on [**2190-5-22**].








[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]

Dictated By:[**Last Name (NamePattern1) 76**]

MEDQUIST36

D: [**2190-7-7**] 08:16
T: [**2190-7-7**] 11:56
JOB#: [**Job Number 77**]
Admission Date: [**2103-4-11**] Discharge Date: [**2103-4-18**]


Service: MEDICINE

Allergies DISEASE :
Enalapril / Ace Inhibitors

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Right arm tingling

Major Surgical or Invasive Procedure:
Left Craniotomy for resection of mass


History of Present Illness:
Asked to eval this 86 year old white RHM who appears younger
than his stated age for newly diagnosed brain mass. He takes
daily ASA and coumadin for AFIB. Pt and wife give history.
They report that he has had frequent falls recently the latest
being yesterday. He did strike his head yeadsterday but did not
have LOC or sz. He has baseline incontinence DISEASE from prostate CA
and straight caths 6 xs day for this. He feels that he has been
falling due to weakness DISEASE on his right side. Due to the falls he
has had exacerbation of his back pain DISEASE . He stopped his coumadin
one week ago for planned EDSI at [**Hospital1 **]. After his
EDSI he walked himself over to a neurology clinic requesting to
be seen - he had imaging and was sent here for neurosurgical
evaluation. Admits to pain DISEASE at back of head Denies dizziness DISEASE
N/V DISEASE sz CP or SOB.


Past Medical History:
HTN DISEASE
MI [**06**]-20 yrs ago (no PPM / no stents)
Prostate CA s/p RT and hormone DISEASE therapy
sleep apnea DISEASE / utilizes CPAP machine
baseline incontinence DISEASE
AFIB
high cholesterol
TB s/p 1 year of medical therapy many years ago.


Social History:
lives with wife at home (one fight of stairs to basement)
retired manager remote tobacco use (quitAdmission Date: [**2103-10-7**] Discharge Date: [**2103-10-11**]

Date of Birth: [**2054-1-14**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 49 year old
woman with a negative past medical history who on the day of
admission noticed numbness DISEASE and tingling of her left side that
progressed to inability to walk. The patient was taken to
[**Hospital3 3583**] where she had a head computerized tomography
scan and magnetic resonance imaging scan which showed a 3.5
cm mass with some surrounding edema DISEASE no mass effect no
midline shift right frontoparietal mass with hyperintense
region.

PAST SURGICAL HISTORY: Cesarean section 14 years ago and
varicose vein stripping.

MEDICATIONS: She is on no medications.

ALLERGIES: She has an allergy DISEASE to sulfa which causes a rash DISEASE .

PHYSICAL EXAMINATION: On physical examination she is awake
alert and oriented times three. Pupils fixed down to 4 mm
bilaterally fluent language and oriented times three. Blood
pressure was 131/69 temperature 98.4 heartrate 91
respiratory rate 11 to 18 saturations 97 to 98%. Lungs were
clear to auscultation. Cardiac was regular rate and rhythm
no murmur rub or gallop positive bowel sounds nontender
nondistended. 2Admission Date: [**2131-4-2**] Discharge Date: [**2131-4-6**]

Date of Birth: [**2074-6-25**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
exertional angina DISEASE

Major Surgical or Invasive Procedure:
cabg x4/RCA endarterectomy [**2131-4-2**] (LIMA to LAD SVG to OM1 and
OM2 SVG to PDA)


History of Present Illness:
56 yo male with several months of recurrent chest discomfort.
Myoview showed large areas of lateral ischemia DISEASE small area of
scar and anteroapical ischemia DISEASE . Cath revealed LM 30% LAD 90%
diag 1 100% diag 2 100% CX 70-90% OM1 70% OM 2 80% OM 3
100% RCA 30-50% PDA 90% EF 50-55% trace MR LVEDP 21.
Referred DISEASE for CABG.

Past Medical History:
HTN DISEASE
elev. chol.
remote fractured sternum
inguinal hernia DISEASE
carpal tunnel syndrome DISEASE
PSH DISEASE : T&A

Social History:
iron worker
lives with wife
smoked 2ppd for 20 years quit 15 years ago
10-15 beers/week

Family History:
brother with CABG at 39 mother with valvular problem

Physical Exam:
HR 78 RR 12 right 122/78 left 120/80
5'9Admission Date: [**2190-6-24**] Discharge Date: [**2190-7-4**]

Date of Birth: [**2134-1-3**] Sex: F

Service: [**Hospital1 **] MEDICINE

HISTORY OF PRESENT ILLNESS: This is a 56-year-old female
with a history of rheumatoid arthritis asthma anemia DISEASE and
status post Nissen fundoplication in [**2173**] for severe
gastroesophageal reflux disease DISEASE transferred from an outside
hospital for possible embolization of a GI bleed DISEASE . The
patient first developed black tarry stools two weeks ago
prior to admission and an EGD at the time showed a small
ulcer DISEASE at the gastroesophageal junction. She received 1 unit
of packed red blood cells and was discharged in stable
condition at that time.

On [**2190-6-21**] three days prior to admission she again
developed black tarry stools. She was scheduled to see Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5656**] her gastroenterologist who performed an EGD on
[**2190-6-23**] one day prior to admission. This EGD showed a
normal upper GI tract. She was admitted to [**Hospital 1263**] Hospital
the following day for a colonoscopy which only showed old
blood in the cecum. A repeat upper GI was done and showed
two clots in the fundus with fresh blood. She was
transferred to the Intensive Care Unit at [**Hospital 1263**] Hospital
and then transferred to the [**Hospital1 188**] for possible angiography and embolization.

At time of admission she denied chest pain DISEASE . She had some
mild shortness of breath DISEASE especially when standing. She did
have dizziness DISEASE when standing. She also had five stools on
the day of admission with her bowel prep. She had one bowel
movement prior to transfer. She denied fever cough DISEASE or
hematemesis DISEASE .

PAST MEDICAL HISTORY:
1. Nissen fundoplication in [**2173**] for severe gastroesophageal reflux disease DISEASE .
2. Asthma.
3. Rheumatoid arthritis DISEASE on Arava methotrexate and Enbrel.
4. Bilateral knee replacements in [**2186**].
5. L5-S1 laminectomies.
6. Iron deficiency anemia DISEASE .
7. Depression DISEASE .
8. Status post splenectomy.

MEDICATIONS AT HOME:
1. Arava 20 mg q day.
2. Methotrexate 25 mg q week.
3. Enbrel 25 mg 2x/week.
4. Prednisone 10 q day which was discontinued in [**2190-2-16**].
5. Prozac 20 q day.
6. Doxepin 100 q day.
7. Folate 2 q day.
8. Premarin 0.3 q day.
9. Medroxyprogesterone 2.75 q day.
10. Protonix 40 [**Hospital1 **].

ALLERGIES:
1. Penicillin which lead to wheezing DISEASE and shortness of breath DISEASE
and itching rash DISEASE .
2. Sulfa which causes hives.

FAMILY HISTORY: Her maternal grandfather had a history of
stomach cancer DISEASE and sister with severe gastroesophageal reflux disease DISEASE . Her father had gastroesophageal reflux DISEASE
disease.

SOCIAL HISTORY: She denies tobacco alcohol or IV drug use.
She is a retired finance worker. She is married with four
children.

REVIEW OF SYSTEMS: As noted above.

PHYSICAL EXAMINATION: On admission she was afebrile with a
temperature of 98.7 blood pressure was 103/54 with a heart
rate of 100 and oxygen saturation of 97% on room air. In
general she was in no acute distress and pale appearing
woman who is obese. Her head and neck examination: Pupils
are equal round and reactive to light and accommodation.
Extraocular motions were intact. Her neck was supple with no
lymphadenopathy DISEASE . Her heart was regular rate and rhythm
with a systolic ejection murmur DISEASE loudest at the left upper
sternal border. Her lungs are clear to auscultation
bilaterally. Abdomen was soft with no active bowel sounds DISEASE
nontender nondistended and no hepatosplenomegaly DISEASE . Her
extremities were warm and well perfused with no clubbing
cyanosis DISEASE or edema DISEASE .

LABORATORIES ON ADMISSION: From outside hospital included a
white count of 5.9 hematocrit of 27.7 platelets of 309000.
Her electrolytes were a sodium of 141 potassium of 4.6
chloride of 104 bicarbonate of 30 BUN 12 creatinine 0.6
glucose 121 calcium 8.4 phosphorus 2.6 magnesium 1.9. Her
coagulation panel included a PT of 12 INR of 1.1 PTT of
25.4.

HOSPITAL COURSE BY PROBLEM:
1. Upper GI bleed DISEASE : The patient was transferred to the
Medical Intensive Care Unit upon admission and was managed
expectantly for any potential bleeding DISEASE . She was transfused 2
units of packed red blood cells and evaluated by the
Gastroenterology Service. They felt that she would benefit
from another esophagogastroduodenoscopy prior to angiography
to further evaluate the possible sources of bleeding DISEASE . She
continued with stable vitals and her EGD showed no active
bleeding DISEASE source or abnormality in the esophagus stomach or
duodenum.

She was continued on observation in the Medical Intensive
Care Unit until her third hospital day where it was felt
that she was stable to return to the Medical floor. In the
following morning however she had a further episode of
black stool as well as dizziness DISEASE upon standing and
tachycardia DISEASE on standing. She was thus taken to the
Angiography Vascular Interventional Suite where a left
gastric artery embolization was performed with gelfoam.
Please see full report for details of the procedure. The
patient tolerated the procedure well with some residual
nausea DISEASE and vomiting DISEASE for which she was returned to the
Medical Intensive Care Unit postoperatively for expectant
management.

The patient also had one episode of chest pain DISEASE during the
procedure that was evaluated with an electrocardiogram and
one set of cardiac enzymes which were both negative for any
evidence of ischemia DISEASE . It was felt that this was likely
secondary to her gastroesophageal reflux disease DISEASE from a
horizontal position.

On hospital day seven the patient was again returned to the
Medical floor after a stable time in the Intensive Care Unit.
She had received 1 unit of packed red blood cells prior to
and during the angiography procedure. Her hematocrit
following this transfusion was 35.2.

For the remainder of her hospital stay the hematocrit
drifted slightly down to 33 with several small episodes of
melena DISEASE . She was continually followed by the Gastroenterology
Service with repeated hematocrits all remaining within the
stable range. Her dizziness DISEASE and tachycardia DISEASE upon standing
resolved and no further blood transfusions were necessary.
Her nausea DISEASE and vomiting DISEASE resolved after her first day
following the procedure and no further evidence of bleed DISEASE was
noted. Her diet was advanced slowly from clear liquids 48
hours after her embolization procedure and she was advanced
to soft solids followed by a regular diet on the day prior to
discharge. She remained pain DISEASE free with stable vitals and no
further evidence of bleed DISEASE on hospital day 11 the day of her
discharge.

2. Shortness of breath DISEASE and hypoxia DISEASE : The patient reported
shortness of breath DISEASE and hypoxia DISEASE that was thought to be
secondary to her anemia DISEASE and deconditioning with decreased
activity over the prior months. However given the patient's
changes in volume with transfusions as well as her lower
extremity edema DISEASE and presence of murmur an echocardiogram was
obtained which showed normal left ventricular function and
ejection fraction as well as no evidence of diastolic
dysfunction. Please see full report for details of the
study.

In addition given her hospitalizations and partial
compliance with Venodynes sequential compression device
boots it was felt that a pulmonary embolism DISEASE was also a
possible cause for her shortness of breath DISEASE . A CT angiogram
was obtained and no evidence of pulmonary embolism DISEASE was
found. The patient remained on oxygen 2 liters nasal cannula
during her early hospitalization however on the final three
days of her hospitalization she was oxygenating 94% on room
air range. She was also able to ambulate without shortness DISEASE
of breath or desaturation DISEASE . It was felt that her hypoxia DISEASE was
possibly secondary to her history of asthma/reactive airways
disease. Further workup as an outpatient is recommended as
needed.

3. Rheumatoid arthritis DISEASE : The patient's rheumatoid arthritis DISEASE
medicines were held during this initial acute episode. She
remained without pain DISEASE or flare of her rheumatoid arthritis DISEASE
however on the final hospital day she complained of some
mild joint symptoms in her hands. It was recommended that
she resume her rheumatoid arthritis DISEASE medicines under
consultation of her primary doctor.

4. Depression DISEASE and anxiety DISEASE : The patient was maintained on her
regimen of Prozac and doxepin as well as receiving Ativan prn
and at hs.

5. Fever DISEASE : The patient had one episode of fever DISEASE following her
GI embolization. This was felt to be secondary to
postoperative response to foreign material within the
vasculature. Her right groin sites where the interventional
catheters were placed showed no signs of infection DISEASE . In
addition her lungs were clear and no urinary symptoms were
identified. She persisted with some mild low-grade fevers DISEASE
for two days following the procedure however the
temperature came down to within her normal range
subsequently. No sign of infection DISEASE was noted and blood
cultures were not sent.

On hospital day 11 the patient was deemed in stable
condition to return home.

CONDITION ON DISCHARGE: Good and stable.

DISCHARGE STATUS: Home with no services.

DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed DISEASE .
2. Rheumatoid arthritis DISEASE .
3. Anxiety/depression.
4. Blood loss anemia DISEASE .
5. Hypovolemia DISEASE .
6. Hypoxia.

DISCHARGE MEDICATIONS:
1. Arava 20 mg q day.
2. Methotrexate 25 mg q week.
3. Enbrel 25 mg 2x/week.
4. Prednisone 10 q day which was discontinued in [**2190-2-16**].
5. Prozac 20 q day.
6. Doxepin 100 q day.
7. Folate 2 q day.
8. Premarin 0.3 q day.
9. Medroxyprogesterone 2.75 q day.
10. Protonix 40 [**Hospital1 **].
11. Omeprazole 40 mg po bid.

FOLLOW-UP PLANS: The patient is instructed to followup with
her gastroenterologist Dr. [**First Name (STitle) 5656**]. Is instructed to return
to the Emergency Department or contact her physician if she
develops any further bleeding DISEASE per rectum dark tarry DISEASE stools
or fevers nausea DISEASE is uncontrolled or vomiting DISEASE .



[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**] M.D. [**MD Number(1) 4521**]

Dictated By:[**Last Name (NamePattern1) 5657**]

MEDQUIST36

D: [**2190-7-5**] 16:35
T: [**2190-7-7**] 08:32
JOB#: [**Job Number 5658**]
Admission Date: [**2155-8-3**] Discharge Date: [**2155-8-17**]

Date of Birth: [**2090-9-8**] Sex: M

Service: CSURG

Allergies DISEASE :
Atenolol / Vasotec / Shellfish

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
redo AVR/MVR DISEASE

History of Present Illness:
This is a 64yo M who presented with c/o progressive SOB for 6
weeks. He has documented significant dysfunction of AV DISEASE over the
past year with planned AVR and possible MVR (not scheduled
yet). Presents with 6 weeks of progressive dyspnea DISEASE with acute
worsening over past 24 hrs. New orthopnea DISEASE . No CP. Mild failure DISEASE
on CXR


Past Medical History:
1.Hypercholesterolemia
2.3V CABG [**2144**]
3.Endocarditis s/p Bioprosthetic in 96AVR
4.HTN
5.DM-2
6.Gout
7.Carotid Stenosis- 40-50% stenosis of R carotid artery in 97
8.Renal Artery Occlusion
9.Toxic Thyroid Nodule DISEASE s/p RAI DISEASE
10.trigger finger release
[**2144**]: IPMI [**2144**] CABG with LIMA to LAD [**Year (4 digits) 5659**] to OM1 and OM2
[**11/2147**]: endocarditis DISEASE
[**2148-2-9**] cardiac catheterization [**Hospital1 18**] for exertional DISEASE arm
discomfort (similar to pre-bypass angina DISEASE ). Widely patent bypass
grafts/native 3vd. Moderate-severe MR [**First Name (Titles) **] [**Last Name (Titles) **] moderate to severe

diastolic dysfunction DISEASE .
[**2148-2-14**] right retinal artery occlusion DISEASE possibly due to aortic
valve associated embolic event DISEASE .
[**2148-3-4**]: AVR [**Hospital6 **]
[**2155-6-17**]: Ruled out for PE. Troponin 0.14. CK's
flat. Diagnosed with CHF captopril DISEASE initiated. Diuresed.

[**2154-6-17**] echo: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated RA DISEASE mildly dilated mild
symmetric LVH DISEASE . Aortic root ascending aorta and arch mildly
dilated. 1Admission Date: [**2164-7-5**] Discharge Date: [**2164-7-11**]

Date of Birth: [**2110-9-19**] Sex: M

Service: CSU


HISTORY OF PRESENT ILLNESS: This is a 51 year old male
patient who noticed to have chest pressure a few hours prior
to admission. He presented to an outside hospital Emergency
Department about 3:00 in the afternoon and was found to have
elevated ST segments. He was started on Integrilin at that
time and was transferred to [**Hospital1 188**] for emergency cardiac catheterization. This revealed
left main and severe three vessel coronary artery disease DISEASE
with a left ventricular ejection fraction of greater than 55
percent and was referred for emergency coronary artery bypass
grafting.

PAST MEDICAL HISTORY: Significant for nephrolithiasis DISEASE status
post stone extraction as well as ankle surgery.

PREOPERATIVE MEDICATIONS: Accupril Metoprolol 100 mg po
bid Lipitor 20 mg po q d Vitamin E and Aspirin daily.

ALLERGIES: The patient states no known drug allergies DISEASE
although he does note an upset stomach with erythromycin.

PHYSICAL EXAMINATION: Upon admission to the hospital was
unremarkable as were his laboratory values with the exception
of elevated CPKs and Troponins.

HOSPITAL COURSE: The patient was taken emergently to the
Operating Room due to his findings in catheterization
laboratory of a 95 percent left main coronary artery
stenosis as well as a 90 percent to 95 percent left anterior
descending coronary artery lesion. 80 percent proximal left
circumflex and an occluded right coronary artery. The
patient was taken to the Operating Room with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] where he underwent coronary artery bypass graft
times three. The patient had an intraaortic balloon pump
placed preoperatively due to his anatomy. Postoperatively he
was transported from the Operating Room to Cardiac Surgery
Recovery Unit in good condition on Propofol and Phenylephrine
drips.

On postoperative day #1 he was weaned from mechanical
ventilation successfully extubated. He remains on Neo-
Synephrine for the next day or so due to some hypotension DISEASE
his cardiac function remained good with a cardiac index of
greater than 3. His intraaortic balloon pump was weaned and
subsequently discontinued on postoperative day #1. The
patient did require some intravenous fluid boluses for
hypotension DISEASE .

On postoperative day #2 the patient had some atrial
fibrillation DISEASE and was placed on Amiodarone because of this.
He was also begun on Lopressor at that time and begun with
diuresis.

The following day the patient had converted back to normal
sinus rhythm. Had remained hemodynamically stable. Had his
Neo-Synephrine drip weaned to off and was tolerating beta
blocker and diuresis.

Postoperative day #3 he was transferred from the intensive
care unit to the telemetry floor. His Metoprolol had been
increased. His [**Location (un) 1661**]-[**Location (un) 1662**] drain in his leg had been
removed and he had begun ambulation and cardiac
rehabilitation. The patient subsequently on the telemetry
floor had another episode of atrial fibrillation DISEASE that was
short lived on [**2164-7-10**] early in the morning that was
self limiting. His Lopressor was increased and he has not
had any further episodes of atrial fibrillation DISEASE . He remains
on Amiodarone and Metoprolol for this.

PHYSICAL EXAMINATION: Today [**2164-7-11**] is as follows:
The patient is afebrile. He is in normal sinus rhythm with a
rate in the mid 70's. His blood pressure is 120/74. Room
air oxygen saturation is 96 percent. Neurologically he is
grossly intact with no apparent deficits. His pulmonary
examination - his lungs are clear to auscultation
bilaterally. Coronary examination is regular rate and
rhythm. His abdomen is soft nontender nondistended. His
extremities are warm without edema DISEASE . His sternal incision as
well as his right leg incisions are all clean and dry with no
erythema DISEASE no drainage. The Steri-strips are intact.

DISCHARGE MEDICATIONS: Lopressor 100 mg po bid Lasix 20 mg
po bid times seven days Potassium Chloride 20 mEq po bid
times seven days Zantac 150 mg po bid Aspirin 325 mg po q
d Plavix 75 mg po q d times three months. Lipitor 20 mg po
q d Percocet 5/325 po q four hours prn pain DISEASE . The patient is
also to continue on Amiodarone 400 mg po tid times one week
then decrease to 400 mg po bid times one week then decrease
400 mg po q d times one week and then decrease to 200 mg po
q d for the remaining week. This is the tentative plan for
Amiodarone loading unless it is altered or until it is
discontinued by the patient's primary cardiologist Dr.
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. The patient is also going home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts cardiac monitor for his Amiodarone loading and this
will be transmitted to the electrophysiology service here at
[**Hospital1 69**].

CONDITION ON DISCHARGE: Good.

The patient is to follow up with is primary care physician
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 5661**] in one to two weeks. He is to follow up with his
primary cardiologist Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] also in one to two
weeks and to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in
approximately five to six weeks.

CONDITION ON DISCHARGE: Good.

DISCHARGE DIAGNOSES:
1. Coronary artery disease DISEASE status post emergent coronary
artery bypass graft.
2. Postoperative atrial fibrillation DISEASE .




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**] [**MD Number(1) 5663**]

Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2164-7-11**] 12:35:25
T: [**2164-7-11**] 14:43:03
Job#: [**Job Number 5665**]
Admission Date: [**2164-2-15**] Discharge Date: [**2164-2-23**]

Date of Birth: [**2117-3-9**] Sex: F

Service: [**Last Name (un) **]


ADMISSION DIAGNOSIS: Colorectal metastases to the liver.

PROCEDURES PERFORMED:
1. She had a right hepatic lobectomy.
2. CT angiography of the chest to rule out a PE.


DETAILS OF HOSPITAL COURSE: Ms. [**Known lastname 2643**] is a 47 year old
female who presented with synchronous colorectal metastases DISEASE
to the liver from a colonic primary. She underwent a colonic
resection in the fall of [**2162**]. Underwent chemotherapy which
resulted in a substantial reduction in the tumor DISEASE volume and
the liver. After completing her chemotherapy course and
preoperative work up including a chest CT and PET scan she
was believed resectable.

She was taken to the operating room on [**2164-2-15**] where
she underwent a right hepatic lobectomy. The procedure was
uncomplicated. She spent 1 day in the intensive care unit and
was transferred to the floor.

On postoperative day #4 she developed a marked hypoxia DISEASE and
tachycardia DISEASE . Was transferred back to the surgical intensive
care unit where she underwent work up for a pulmonary
embolus. No embolus was identified. Chest x-ray was
unremarkable. Over the next 24 hours her oxygen requirement
decreased and she was transferred back to the floor. Hospital
stay was unremarkable. The pathology report demonstrated no
residual tumor DISEASE within the liver specimen.

She was discharged home on [**2164-2-23**]. She will follow up
with Dr. [**First Name (STitle) **] in 1 week.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] [**MD Number(1) 3432**]

Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2164-4-2**] 07:19:44
T: [**2164-4-2**] 07:42:15
Job#: [**Job Number 5666**]
Admission Date: [**2101-12-17**] Discharge Date: [**2101-12-22**]

Date of Birth: [**2045-5-15**] Sex: M

Service: PLASTIC

Allergies DISEASE :
Novocain

Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
left multidigit trauma DISEASE s/p table saw injury


Major Surgical or Invasive Procedure:
1. left index digital artery digital nerve repair radial and
ulnar nerve repair x2
2. radial lateral collateral ligament repair
3. left long finger radial digital artery repair
4. left long finger digital artery digital nerve radial and
ulnar repair x2
5. left long finger flexor digitorum profundus repair
6. left ring finger radial digital artery repair with
microvascular anastomosis
7. left ring finger radial and ulnar digital nerve repair x2
8. left ring finger flexor digitorum profundus repair
9. A1 pulley release
10. repair of lacerations 20-cm
11. dissection of dorsal vein for vein graft harvest


History of Present Illness:
56yo male right-hand dominant OSH transfer with traumatic injury DISEASE
to left hand with table saw at approximately 1230p today.
Patient states hand slipped and was caught by table saw.
Immediately after the incident patient reports moderate pain DISEASE
and placed clenched injured hand in right hand and proceeded to
emergency department. Patient notes general numbness DISEASE of digits
[**1-26**] and inability to flex digit 4. Patient received cefazolin
and tetanus DISEASE booster at outside hospital.

Past Medical History:
MI ([**2081**]) hyperlipidemia DISEASE GERD nephrotic syndrome DISEASE
pneumothorax DISEASE


Social History:
works as commercial driver
tob - 2pk/day prev 4pk/day
EtOH - social
illicit - denies


Family History:
non-contributory

Physical Exam:
upon admission:
General - AOx3 NAD
Chest - CTAB
CV - RRR S1/S2 appreciated
Abd - soft nontender nondistended
Extremity - left upper extremity: patient with significant
multiple injuries of the hand as follows.
1st digit: laceration of the volar aspect along the MCP no
exposed tendonAdmission Date: [**2190-3-8**] Discharge Date: [**2190-3-16**]

Date of Birth: [**2107-11-21**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Heparin Agents

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
N-G tube placement

History of Present Illness:
Mr. [**Known lastname **] is an 82 yo male s/p prolonged hospital and
rehabilitation course following XRT for [**Location (un) 5668**] cell carcinoma
who presents with acute onset shortness of breath DISEASE at [**Hospital 100**]
Rehab earlier today. Per report oxygen saturation dropped to
84-85% on 4L NC from baseline in the mid 90's. He was
hypotensive DISEASE with SBP's in the 80's which resolved with IVF. Per
report from [**Hospital 100**] Rehab patient was noted to have new thick
brown sputum with difficulty swallowing. He was recently started
on levofloxacin/flagyl three days ago for treatment of a
presumed aspiration pneumonia DISEASE .
.
Of note he was admitted to NEBH in [**Month (only) 1096**] for Admission Date: [**2149-10-15**] Discharge Date: [**2149-10-20**]

Date of Birth: [**2083-9-18**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Niaspan Extended-Release

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Exertional chest heaviness DISEASE

Major Surgical or Invasive Procedure:
[**2149-10-15**] Coronary artery bypass grafting x4 with the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein grafts to the distal right coronary
artery first and second obtuse marginal arteries.

History of Present Illness:
66 year old male with a 2 week history of chest burning DISEASE which
occurs about 10-15 minutes into his daily 1 mile walk. It lasts
for 20-30 seconds and then resolves and he is able to finish
walking his mile. He notes that he does not get the symptoms
everytime he walks. He denies any symptoms at rest. He does note
waking up with bilateral ankle/feet pain/throbbing at night. He
was referred for a cardiac catheterization and was found to have
coronary artery disease DISEASE . He is now being referred to cardiac
surgery for revascularization.

Past Medical History:
Diabetes Type II DISEASE
Hypertension DISEASE
Hyperlipidemia DISEASE
Osteoarthritis DISEASE
Lumbar disc disease DISEASE
Proteinuria DISEASE
Polyps DISEASE on colonoscopy
s/p left knee scope x 4

Social History:
Race:Caucasian
Last Dental Exam: 10 years ago
Lives with:Wife
Contact:[**Name (NI) 4457**] (wife) Phone #[**Telephone/Fax (1) 5671**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: denies
Illicit drug use:denies

Family History:
Premature coronary artery disease DISEASE - uncle had a
heart transplant in his early 50's. Father had 3 MI's first in
his 40's. Brother had CABG at age 59.

Physical Exam:
Pulse:60 Resp:16 O2 sat:100/RA
B/P Right:168/87 Left:179/80
Height:5'8Admission Date: [**2175-3-12**] Discharge Date: [**2175-3-24**]

Date of Birth: [**2105-11-5**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Progressive lethargy DISEASE and collapse

Major Surgical or Invasive Procedure:
ACA aneursym DISEASE coiling

History of Present Illness:
HPI: This is a 69 year old male who is primarily Russian
speaking
who was reportedly outside fishing when he slipped and fell.He
now presents to the ED with his wife who reports that he has
become progressively lethargic today. The patient is unable to
report a review of systems due to his lethargy DISEASE . Upon seeing the
patient we recommended an emergent CTA.


Past Medical History:
PMHx: spondylosis DISEASE chronic low back pain DISEASE associated with
degenerative changes. Followed by Dr. [**Last Name (STitle) 79**] for prostate cancer DISEASE .
Chronic lymphocytic leukemia DISEASE which has been very stable.

Social History:
Lives with Wife

Family History:
NC

Physical Exam:
On Admition:

Gen: lethargic atraumatic
HEENT: Pupils: PERRL 4-mm EOMs pt not participating in exam
Neuro:
Mental status: opens eyes to stimulation lethargic.
Orientation: not answering questions but following simple
commands
Language:pt lethargic/non verbal at time of exam and emergently
brought to CTA-
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light 4 to 3
mm bilaterally. Visual fields- not tested
III IV VI: Extraocular movements- not tested
V VII: Facial strength and sensation intact and symmetric.
VIII: [**Name (NI) 80**] pt did not participate
IX X: Palatal elevation- pt did not participate
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius- pt did not participate
XII: [**Name (NI) 82**] pt did not participate.
Motor: Normal bulk and tone bilaterally. No abnormal movements DISEASE
tremors DISEASE . Strength appears full pt grips with bilat hands [**5-9**]
lifts all extremities off the bed to command
Sensation: Intact to light touch proprioception pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: pt too lethargic to perform


Pertinent Results:
CT head:
Extensive bilateral subarachnoid hemorrhage DISEASE . Recommend head CTA
to evaluate for an intracranial aneurysm DISEASE .
Findings were discussed with Dr.

CTA:
FINDINGS: There is a 3 mm x 3 mm saccular outpouching from the
region of the anterior communicating artery (2:317) consistent
with aneurysm DISEASE . This has a very narrow neck and would be
amenable to endovascular intervention. No other aneurysm DISEASE or
vascular abnormality DISEASE is seen.
There is stenosis at the origin of the right vertebral artery.
Otherwise the carotid and vertebral arteries and their major
branches are patent with no evidence of stenosis DISEASE or occlusion.
The distal cervical internal carotid arteries measure 5 mm on
the right and 5 mm on the left.
Mild-to-moderate multilevel cervical spine degenerative DISEASE changes
are noted.
IMPRESSION: 3 mm saccular aneurysm DISEASE arising from the anterior
communicating
artery with narrow neck.


Brief Hospital Course:
Mr. [**Known lastname 83**] was admited on [**2175-3-12**] and became increasingly
lethargic and transferred to the ICU for further care under the
Neurosurgery service. A diagnostic CTA revealed a large ACOM DISEASE
aneursym which was coiled the following day.

Post Coiling the pt. was admitted to the ICU with a ventricular
drain. There were no incidences of increased intracranial
pressure or decline. A cerebral perfusion study performed [**3-15**]
confirmed the lack of vasospasm DISEASE and develoing strokes DISEASE .

He had some R shoulder weakness and shoulder X-ray was
concerning for rotator cuff injury and orthopedics was
consulted.

On [**2179-3-16**]/14/15 his ventricular drain was clamped and reopened
due to elevated ICP levels. On [**3-19**] he was transferred to the
SDU and continued to remain stable. He had his ventricular
drain clamped on [**3-21**] and after 48 hours of the clamping trial
he had a CT done which was stable without any evidence of
hydrocephalus DISEASE . At this time the drain was pulled.

He was placed on a fluid restriction for a brief period of time
for a drop in his Na level and also on salt tabs upon
discharge to rehab we have removed the fluid restriction but we
are continuing the salt tabs we advise that the Na level be
checked every other day and the salt tabs may be d/c'ed when Na
is stable on serial checks. Upon discharge his Na is 138.

He is now ready for discharge to rehab.

On discharge his exam is as follows:

Alert and Oriented X2
Moving all extremities with full strength
slight Right Drift which has been persistant throughout his
hospitalization and possibly secondary to a rotator cuff
injury.


Medications on Admission:
[**Name (NI) 84**] wife

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Bisacodyl 5 mg Tablet Delayed Release (E.C.) Sig: Two (2)
Tablet Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Heparin (Porcine) 5000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-6**]
Tablets PO Q4H (every 4 hours) as needed for Headaches DISEASE .
11. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every
4 hours): Continue for [**2175-4-2**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Acom Aneursym
Subarachnoid Hemorrhage DISEASE


Discharge Condition:
Stable

Discharge Instructions:
General Instructions

Admission Date: [**2117-7-7**] Discharge Date: [**2117-7-12**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Lightheadedness dizziness DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Age over 90 **] yo M with no prior cardiac hx following p/w 2 day history of
light-headedness weakness sweating dizziness DISEASE . Symptoms
started while he was out for a walk on Monday where he had a
sudden onset of lightheadedness DISEASE and he had to sit down. The
symptoms have been continuous since Monday. His son notes that
the patient is normally very active and independent for ADLs.
Patient took some of his neighbor's dizziness medication' which
is believed to be meclizine also took some additional Ambien
possibly 15mg. His denied chest pain DISEASE arm pain diaphoresis DISEASE on
admission.

In the ED his initial vitals were 98.9 125/64 106 20 95% on
RA DISEASE . EKG showed new atrial flutter DISEASE with varying conduction and
old LBBB DISEASE . He received Diltiazem 10mg PO with good HR response
into 80s. Son describes notable improvement s/p treatment in ED.
On arrival to the floor 96.1 128/84 80 20 93% on 2L NC. He
has no home O2 requirement.

At 10pm pt received ambien and 30mg po diltiazem--per nurse he
was in NAD. 30 minutes later he was found restless DISEASE and
diaphoretic with satAdmission Date: [**2184-8-4**] Discharge Date: [**2184-8-10**]

Date of Birth: [**2112-1-20**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Shortness of Breath DISEASE

Major Surgical or Invasive Procedure:
[**2184-8-5**]: Cardiac catheterization no intervention

History of Present Illness:
72 yo F with PMHx of 2vessel CAD s/p RCA atherectomy in '[**67**]
HTN DISEASE morbid obesity Hyperlipidemia DISEASE who presents with dyspnea DISEASE x
3days worse past day with a dry cough DISEASE . Symptoms started
abruptly on Sunday night with SOB while walking to bathroom. SOB
remaind persistent over the following days with worsening DOE.
She initially presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5678**] hospital and was found to
be hypotensive DISEASE and was transferred to [**Hospital1 18**] ED with suggested
diagnosis of PNA incidentally found to have elevated troponin
of 1.73. She was started on heparain at OSH. Received azithro
and Ceftriaxone at OSH. Was on neo at 100 mcg. Got RIJ in our
ED. Crackles at bases Febrile DISEASE to 100.1. Gave levofloxacin. Put
on levophed in ED. O2 sat high 90's on 4L. CXR here appears to
have bilateral infiltrates. ECG here afib rate [**Street Address(2) 5679**]
elevations V4-V6. Patient denies chest pain DISEASE .
.
On review of systems (limited as pt poor insight) she denies
any prior history of stroke TIA DISEASE deep venous thrombosis DISEASE
pulmonary embolism bleeding DISEASE at the time of surgery myalgias DISEASE
joint pains cough hemoptysis DISEASE black stools or red stools. She
denies recent fevers chills DISEASE or rigors DISEASE .
.
Cardiac review of systems is notable for absence of chest pain DISEASE
but worsening dyspnea DISEASE on exertion she endorses unchanged
paroxysmal nocturnal dyspnea DISEASE and nocturia orthopnea DISEASE which is
unchanged no ankle edema DISEASE no palpitations DISEASE no syncope DISEASE or
presyncope DISEASE .
.

Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia Hypertension DISEASE
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: 93 RCA atherectomy
3. OTHER PAST MEDICAL HISTORY:
Hypertension DISEASE
Obesity DISEASE
Paroxismal Afib DISEASE
Asthma

Social History:
Pt lives alone in an atp in [**Location (un) 5680**]. She is very sedentary and
is able to function on a routine. She has 2 daughters who live
nearby and help her extensively. Will likely need placement at
[**Hospital3 **] or other facility after discharge.

Family History:
No family history of early MI arrhythmia cardiomyopathies DISEASE or
sudden cardiac deathAdmission Date: [**2158-9-11**] Discharge Date: [**2158-9-15**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Failure to thrive acute renal failure mental status DISEASE change
tremor DISEASE

Major Surgical or Invasive Procedure:
G-tube placement

History of Present Illness:
86 yo F with dementia HTN CKD DISEASE with recent discharges from
[**Hospital1 18**] for FTT ARF DISEASE and UTI DISEASE admitted today from rehab due to poor
PO intake and concern of new body tremors/neck spasmAdmission Date: [**2174-9-8**] Discharge Date: [**2174-9-11**]

Date of Birth: [**2119-3-4**] Sex: M

Service: SURGERY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
acute L leg ischemia DISEASE

Major Surgical or Invasive Procedure:
Left femoral embolectomy and vein patch angioplasty.


History of Present Illness:
This 55-year-old gentleman presented to our emergency room last
night with an acutely ischemic left foot which had been present
for several hours. He was placed on heparin with significant
improvement in symptoms. He had absent pulses distal to the
groin on the left with intact pulses throughout on the right. He
is now being explored for possible embolectomy.

Past Medical History:
PMH:

MI
HIV
HTN DISEASE

Social History:
He denies any use of alcohol or IV drugs. He has smoked [**1-30**]
packs of cigarettes per day for the last 30 years.

Family History:
non contributary

Physical Exam:
HEENT:
No thrush. Neck is supple.
Full range of motion. No lymphadenopathy DISEASE .
CHEST:
is clear to auscultation bilaterally.
HEART:
regular rate and rhythm without gallops or rubs noted. There is
a III/VI murmur noted at the left lower sternal border to the
left upper sternal border.
ABDOMEN:
is soft nontender nondistended. There were
bowel sounds noted.
RECTAL:
There is no stool in the vault. The fluid in the vault is occult
blood negative.
EXTREMITIES:
without clubbing cyanosis DISEASE or edema DISEASE .
NUEROLOGICAL EXAMINATION:
Awake alert and oriented x3.
Cranial nerves motor examination and sensory examination were
normal.
The toes were down-going bilaterally.

Pertinent Results:
[**2174-9-11**]

WBC-6.0 RBC-2.66* Hgb-11.9* Hct-31.4* MCV-118* MCH-44.7*
MCHC-37.8* RDW-13.4 Plt Ct-184

[**2174-9-11**]

Plt Ct-184

[**2174-9-11**]

PT-12.4 PTT-27.7 INR(PT)-1.0

[**2174-9-11**]

Glucose-93 UreaN-15 Creat-0.9 Na-141 K-4.1 Cl-107 HCO3-27
AnGap-11
[**2174-9-8**]

CK(CPK)-409*

[**2174-9-11**]

Calcium-8.9 Phos-2.9 Mg-1.7

Cardiology Report ECG Study Date of [**2174-9-8**] 11:30:44 AM


Baseline artifact. Sinus rhythm. Q waves in the anterior leads
consistent with prior infarction DISEASE . Probable left atrial
abnormality. Compared to the previous tracing of [**2169-3-14**] the
rate is faster.

Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 168 96 [**Telephone/Fax (2) 5693**] 57

[**2174-9-8**] 2:07 PM

CHEST (PRE-OP PA & LAT)

Reason: pt preop vascular surgery

[**Hospital 93**] MEDICAL CONDITION:
55 year old man with new onset pain DISEASE L leg/blanching and pulses
diminished. Arterial clot
REASON FOR THIS EXAMINATION:
pt preop vascular surgery
INDICATION: Left leg blanching DISEASE and decreased pulses
preoperative study for vascular surgery.

No studies are available for comparison on PACs.

AP UPRIGHT AND LATERAL VIEWS OF THE CHEST: The heart size is
normal. The mediastinal and hilar contours are normal. The lungs
are clear. There is no pleural effusion DISEASE or pneumothorax DISEASE . The
osseous structures are unremarkable.

IMPRESSION: No evidence of acute cardiopulmonary process.

GENERAL URINE INFORMATION

Type Color Appear Sp [**Last Name (un) **]
Straw Clear 1.008

Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
SM NEG NEG NEG NEG NEG NEG 6.5 NEG

RBC WBC Bacteri Yeast Epi
0-2 0-2 NONE NONE 0-2




Brief Hospital Course:
Pt admitted on [**2174-9-11**]

Stared on heparin.

Pt undergoes a Left femoral embolectomy and vein patch
angioplasty. Pt tolerates the procedure well. There were no
complications. Flow was re-established into
the profunda femoris first and then into the superficial femoral
artery. Doppler interrogation demonstrated good flow in both
branches and there was a strongly palpable dorsalis pedis pulse.
Pt extubated in the OR. Pt transfered to the PACU in stable
condition.

Once recovered from anesthesia. Pt transfered to the PACU in
stable condition.

Once recovered from anesthesia pt transfered to the VICU
instable condition.

IV Heparin started / coumadin started.

[**2174-9-12**]

Pt delined diet was advanced as tolerated.

PT consult was obtained. Pt was allowed to get OOB to chair.

[**2174-9-13**] - Discharge

Pt stable PTT was monitered / On Discharge pt INR not at desired
level. Pt [**Name (NI) 1788**] on lovenox for bridge over to couamdin DISEASE .

On discharge pt is stable / taking PO / ambulating / pos BM /
urinating without difficulty.


Medications on Admission:
lopressor 25'
combivir
viramune
lisinopril
lipitor
aspirin

Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous once a day: Continue lovenox daily until INR is at
least 2.0.
Disp:*30 syringes* Refills:*0*
2. Outpatient [**Name (NI) **] Work
PT INR labs every other day until INR is at least 2.0. Please
have the [**Name (NI) **] fax the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD.
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*40 Tablet(s)* Refills:*0*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*6*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation DISEASE .
Disp:*60 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
primary diagnosis
1) Thromboembolism DISEASE s/p embolectomy and vein patch angioplasty.

secondary diagnosis
2) HIV
3) HTN DISEASE
4) h/o MI


Discharge Condition:
good


Discharge Instructions:
Please resume all your home medications as before as well as the
ones prescribed to you upon discharge from the hospital. If you
experience fevers chills DISEASE leg pain DISEASE or severe bleeding DISEASE from
your incisions please report to the emergency department.

Please do not drive for one week. Please keep your dressing on
till Monday. You may take a shower on Monday. Please do not
soak in baths or swim in pools.

Please be careful with falls and bumps because of increased risk
of bleeding DISEASE with lovenox and coumadin.

Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week to follow
up your blood coagulation DISEASE times (PT/INR). Please call ([**Telephone/Fax (1) 5694**] to make an appointment. Dr. [**Last Name (STitle) **] will also set up
a TTE to evaluate your heart. Thank you.

Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks. Please
call [**Telephone/Fax (1) 3121**] to make an appointment.



Completed by:[**2174-11-1**]Admission Date: [**2174-9-8**] Discharge Date: [**2174-9-11**]

Date of Birth: [**2119-3-4**] Sex: M

Service: VSU


CHIEF COMPLAINT: Left leg ischemia DISEASE .

HISTORY OF PRESENT ILLNESS: This is a 55 year old gentleman
with HIV coronary artery disease DISEASE status post myocardial
infarction DISEASE who woke up at 1:00 a.m. with an ice cold left
leg from the upper thigh to the foot. He admits to pain DISEASE in
the calf and numbness DISEASE . Symptoms improved by 5:00 a.m. but
pain DISEASE continued. The patient went to the emergency room at an
outside hospital at [**Hospital3 417**] Hospital in [**Hospital1 1474**]
where he was evaluated. The patient was begun on IV heparin
and transferred here for further evaluation and treatment.

On arrival to our emergency room vascular service was
consulted. The patient was admitted to the vascular service
for definitive care.

PAST MEDICAL HISTORY: Allergies to penicillin
manifestations unknown. Illnesses include coronary artery
disease and myocardial infarction DISEASE at the age of 49 status
post angioplasty. History of HIV. History of hypertension DISEASE .

PAST SURGICAL HISTORY: No past surgical history.

MEDICATIONS: Lopressor XL 25 mg dailyAdmission Date: [**2179-4-28**] Discharge Date: [**2179-5-3**]

Date of Birth: [**2119-3-4**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
post infarction angina DISEASE

Major Surgical or Invasive Procedure:
coronary artery bypass grafts x
4(LIMA-LADSVG-DiagSVG-OMSVG-PDA)


History of Present Illness:
This 60 year old white male developed chest pain DISEASE on [**4-17**]
while driving. He was found to be bradycardic in the 40s and
was admitted to [**Hospital3 417**] Hospital and ruled in for
infarction DISEASE with a Troponin of 11. Angioplasty and DES were
performed to the mid right coronary. A stress test was
performed prior to discharge and was positive with ECG changes
and pain DISEASE . He was transferred here after recatheterization
revealed triple vessel disease DISEASE .

Past Medical History:
Coronary artery disease DISEASE
s/p stents x 2 to left anterior descending
hypertension DISEASE
HIV positive
s/p right carotid endarterectomy
peripheral vascular disease DISEASE
h/o deep vein thrombophlebitis DISEASE


Social History:
He denies any use of alcohol or IV drugs. He has smoked [**1-30**]
packs of cigarettes per day for the last 30 years.


Family History:
non contributary

Physical Exam:
Admsiision:
Pulse: 72 Resp:17 O2 sat: 98% on RA DISEASE
B/P Right: Left:
Height:5'[**80**]Admission Date: [**2131-9-2**] Discharge Date: [**2131-9-4**]

Date of Birth: [**2073-4-29**] Sex: F

Service: SURGERY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
abdominal pain DISEASE

Major Surgical or Invasive Procedure:
s/p exploratory laparotomy sigmoid colectomy temporary
abdominal closure [**2131-9-3**]
s/p exploratory lapartomy small bowel DISEASE resection temporary
abdominal closure [**2131-9-4**]

History of Present Illness:
58yoF w/ DMAdmission Date: [**2149-1-24**] Discharge Date: [**2149-2-4**]

Date of Birth: [**2087-11-13**] Sex: M

Service: Med


CHIEF COMPLAINT: Gastric varices.

HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
male with past medical history of chronic hepatitis B DISEASE
complicated by cirrhosis portal hypertension gastric varices and hepatic encephalopathy DISEASE (failed interferon and
lamivudine therapy in the past and now on Hepsera DISEASE for
hepatitis B DISEASE ) initially transferred from [**Hospital3 417**]
Hospital on [**2149-1-24**] in preparation for TIPS procedure. The
patient was admitted to [**Hospital3 417**] Hospital with 1-week
history of right-sided abdominal pain DISEASE episode of large
bloody emesis DISEASE with clots and positive melena. EGD on
[**2149-1-13**] at the outside hospital revealed large gastric
varices with dark blood in the stomach and duodenum but no
active bleeding DISEASE . On [**2149-1-22**] the patient became obtunded
and was given octreotide drip and lactulose for hepatic
encephalopathy DISEASE . Surgery was consulted who recommended TIPS.
The patient was then transferred to [**Hospital1 18**] MICU and was
somnolent on arrival. EGD performed on [**2149-1-25**] showed no
esophageal varices 2 erosions DISEASE in the antrum with clean
bases no recent bleed DISEASE appearance consistent with portal
gastropathyAdmission Date: [**2149-7-30**] Discharge Date: [**2149-8-5**]

Date of Birth: [**2087-11-13**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Confusion DISEASE & agitation DISEASE

Major Surgical or Invasive Procedure:
Endotracheal intubation
Central venous line & arterial line placement
EEG

History of Present Illness:
61yo male with HBV cirrhosis DISEASE complicated by portal HTN DISEASE
gastric varicies and s/p TIPS who was transferred to [**Hospital1 18**] from
outside facility for confusion DISEASE & agitation DISEASE . He was also noted
to be jaundiced DISEASE with asterixis DISEASE . Pt had also sustained a fall
with facial trauma DISEASE several weeks ago.
In the ED he desaturated to 80% on 6L/NC and was found to
have EKG evidence of an acute anterior MI. He was intubated for
airway protection & seen by cardiology. He had an emergent ECHO
which demonstrated an EF of 40-50%. He was felt to be too high
risk for anticoagulation or catheterization and was treated
medically with beta-blocker aspirin and plavix. He also
received a chest CTA to evaluate a widened mediastinum & LLL
consolidation prior to transfer to MICU.


Past Medical History:
HBV with cirrhosis DISEASE
Portal hypertension DISEASE
Gastric varicies
s/p TIPS [**1-/2149**]
Hepatic encephalopathy DISEASE
HPV
Gastroparesis DISEASE
Diverticulosis DISEASE s/p partial colectomy
s/p cholecystectomy
Hypothyroidism DISEASE
Liver hemangioma DISEASE s/p radiofreq-ablation
s/p R knee surgery

Social History:
Lives with partner.
Worked as a volunteer Admission Date: [**2114-3-26**] Discharge Date: [**2114-4-19**]

Date of Birth: [**2037-3-25**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
constipation DISEASE w/ inability to void- developed chest pain DISEASE in ER

Major Surgical or Invasive Procedure:
[**2114-4-2**] urgent CABG x2 (LIMA to LAD SVG to PDA)
[**2114-4-11**] PEG
[**2114-4-16**] Trach


History of Present Illness:
76M h/o Diabetes HTN hypercholesterolemia DISEASE h/o CVA DISEASE elevated
PSA on warfarin arrives with 5 days of inability to void and
7day h/o constipation DISEASE . Poor historian with reported poor follow
up history in chart and unclear about what meds he takes at
home. Tried suppositories and laxatives without effect initially
but then states that he had small BM yesterday at home. Last
colonoscopy was over 10 yrs ago per pt. Arrived in ED because he
states Dr. [**Last Name (STitle) 5717**] was not in office - he mainly arrives with c/o
urinary retention. Of note it appears that he was on flomax in
past and has been referred to urology for w/u with elevated PSA
around 6 but he states he is no longer taking this med. He also
failed to f/u with urology for prostate bx. Denies abd pain DISEASE
n/v or any other sx.
In ED vitals were 98.8 57 124/61 16 97% RA DISEASE . KUB consistant
with constipation DISEASE no stool in rectum. Foley was placed and
urine relieved. Given enema with another small BM pt states
that now his bowels are relieved. Labs notable for Cr 1.5
(baseline 1.1) Na slightly elevated to 146 c/w dehydration DISEASE . On
transfer from ED to floor pt was comfortable without pain DISEASE and
only concerned for urinary retention.
During the course of his hospitalization he experienced chest
pain DISEASE and shortness of breath DISEASE . His pain DISEASE was reported to radiate
from to his throat and resolved with sublingual nitroglycerin
and oxygen administration. ECG demonstrated LBBB with ST
depressions DISEASE in II and AVF which resolved. CE Tn 0.02 -Admission Date: [**2199-1-22**] Discharge Date: [**2199-2-12**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypernatremia DISEASE unresponsiveness

Major Surgical or Invasive Procedure:
PEG/trach

History of Present Illness:
[**Age over 90 **]yo F with history of dementia diabetes mellitus DISEASE
hypertension CVA DISEASE Russian speaking woman who was found
unresponsive at [**Hospital 100**] Rehab. On [**2199-1-21**] she was noted to have
difficulty in swallowing. She was placed on NC for 88%RA. On
morning of [**2199-1-22**] she desaturated to low 90s on 5 L. She was
then noted to be unresponsive with left eye sluggish right
faical droop right arm flaccid mottled right extremities and
vitals 118/68 P104 RR40 T 99.8 and 90% on 5L.
In ED patient found to be hypernatremic DISEASE and recieved 2L of NS.
CXR was concerning for RLL PNA and she was started on
levo/flagyl. She was also reported to be more lethargic in the
past 1-2 weeks.
Per PCP [**Name10 (NameIs) **] baseline 1 week ago she has been sitting up in the
chair pleasantly demented but interactive.

Past Medical History:
1. [**2198-11-16**] PRIF of left distal femur fracture DISEASE with [**Last Name (un) 101**]
plate(require 4 person lift followed by ortho clinic)
2. [**8-21**]:ORIF of right intreathrochanteric hip fracture DISEASE
3. osteoporosis DISEASE
4. CVA DISEASE in [**2189**]
5. hypertension DISEASE
6. dementia DISEASE
7. diabetes mellitus-diet DISEASE controlled
8. h/o meningioma DISEASE
9. history of falls
10. cataracts DISEASE

Dementia DISEASE
DM DISEASE
hypertension DISEASE
CVA DISEASE

Social History:
TOB-deniesETOH-denies

Family History:
lives at [**Hospital3 102**]

Physical Exam:
T97.3 P88 BP112/32 NSRon NRB DISEASE 100%
Gen-elderly woman NAD pale and lethargic
neuro-arousable groans in response to pain DISEASE non-conversational
cannot assess orientation cannot assess other neuro exam
CV-faint heart sounds RRR
resp-rhonchi diffusely no crackles no accessory muscle use
[**Last Name (un) 103**]-no BS soft NT/ND DISEASE no HSM
skin-stage 2 decubitus ulcer DISEASE at coccyx region


Pertinent Results:
CT head [**2199-1-22**]:
No evidence of acute intracranial hemorrhage DISEASE or major cortical
territorial infarction.

CXR [**2199-1-22**]:
: New right lower lobe confluent opacity DISEASE which may represent a
developing area of pneumonia DISEASE . Differential diagnosis includes
aspiration and
atelectasis DISEASE . Dedicated PA and lateral chest radiograph is
suggested for more
complete characterization when the patient's condition permits.

no contrast head CT [**2199-1-28**]
FINDINGS: There has been interval development of an area of
decreased attenuation at the left basal ganglia and
periventricular white matter in the distribution of the left
lenticulostriate artery consistent with a subacute infarct DISEASE .
There is associated swelling DISEASE with mass effect on the left
lateral ventricle. There is no shift of normally midline
structures. Additional areas of hypodensity DISEASE in the
periventricular white matter and right centrum semiovale are
unchanged and consistent with old infarctions DISEASE . Two calcified
meningiomas DISEASE are again seen arising at the left frontal dura and
anterior olfactory groove. They are unchanged from prior study.
No intracranial hemorrhage DISEASE was identified. Surrounding osseous
and soft-tissue structures are unremarkable.

IMPRESSION: Subacute left lenticulostriate infarction which was
not present on head CT of [**2199-1-22**]

echo [**2199-1-28**]:

The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEFAdmission Date: [**2183-10-11**] Discharge Date: [**2183-10-24**]

Date of Birth: [**2128-1-16**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Sudafed

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hemoptysis DISEASE

Major Surgical or Invasive Procedure:
Bronchoscopy on [**2183-10-11**] and [**2183-10-17**]
[**2183-10-11**]: IR embolization of an intercostal/bronchial artery
trunk
supplying the right lower lobe.
[**2183-10-13**] IR Successful embolization of right bronchial artery
[**2183-10-15**]: IR embolization of two right intercostal arteries
supplying lung parenchyma
Intubation
PICC line

History of Present Illness:
Mr. [**Known lastname 5721**] is a 55yo M with history of NSCLC DISEASE s/p chemo XRT
and surgery in [**2178**] with post-rad pulm fibrosis bronchiectasis DISEASE
and emphysema DISEASE who presented with hemoptysis DISEASE . He developed a
cough DISEASE with frank blood two days prior to admission and
presented to an OSH for evaluation. There he had stable vital
signs and hematocrit and had a CTA which showed bilateral lower
lobe ground glass opacities pulmonary herosiderosis DISEASE vs.
atypical PNA. Patient refused ambulance transfer to [**Hospital1 18**] and
presented to our ED this AM.
.
In the ED initial vs were: 98.8 103 122/100 20 100%.
Patient was given ativan for anxiety DISEASE approximately one liter of
NS and continued on levaquin which was started on [**10-10**] by his
oncologist. Thoracics was consulted and recommended discussing
his case with IP for possible bronch. Patient had witnessed
hemoptysis DISEASE of approximately 200cc of frank blood in the ED and
has 4 units crossed. His hematocrit and vitals were stable with
SBP in the 120s and heart rate in the 90s-100s. His EKG was
unremarkable. Thoracics wants on west for OR access if
necessary possibly bronch tomorrow or monday. Had 100-200cc
hemoptysis DISEASE here and once at home today. 3 total episodes of
large bleeding DISEASE . Satting 100% on Ra. Got levoflox in ED.
.
On the floor He denied other complaints.


Past Medical History:
Non-small cell lung cancer DISEASE : large cell carcinoma DISEASE (locally
advanced clinical stage T4 N0-1 M0) in [**2177**].
s/p neoadjuvant chemotherapy (Carboplatin/Taxotere) [**9-13**]
s/p chemoradiation DISEASE (Radiation Admission Date: [**2180-9-24**] Discharge Date: [**2180-9-28**]


Service: UROLOGY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 5724**]
Chief Complaint:
Hematuria DISEASE

Major Surgical or Invasive Procedure:
Cystoscopy clot evacuation prostatic urethra fulguration Dr.
[**Last Name (STitle) 986**] [**2180-9-26**].


History of Present Illness:
86 y/o male with hx of BPH and indwelling foley catheter
presenting to the ED with 3 days of hematuria DISEASE . He came to the
ED on [**9-23**] with hematuria DISEASE and was discharged to his nursing home
with instructions to irrigate the catheter as needed and follow
up with Dr. [**Last Name (STitle) 986**] as an outpatient. Last night the nursing
home was unable to irrigate his catheter. They removed his
catheter and were unable to replace the catheter. He failed to
void and had suprapubic discomfort. He was taken to the ED and
an 18F 3 way foley was placed with gross hematuria DISEASE drainage.
CBI was started but the catheter stopped draining. He finished
5 doses of levaquin on [**2180-9-23**]. He was recently admitted to [**Hospital1 2025**]
s/p fall/failure to thrive. Of note he had a voiding trial on
[**2180-9-12**] which he failed. History is obtained from the patient's
wife and through [**Name (NI) **] translator/ ED resident.

Past Medical History:
PMH:
BPH
Indwelling foley catheter
HTN DISEASE
CAD s/p MI [**2170**]
Hx orthostatic hypotension DISEASE
Hx of falls
Vit D deficiency

PSH DISEASE :
None


Social History:
Normally lives with his wife at home. Admitted to [**Hospital3 **]
on [**2180-9-6**] after discharge from [**Hospital1 2025**]. No tobacco/EtOH.


Physical Exam:
VS: Afebrile HR 83 BP 146/81 RR 20 97%RA
NAD A&Ox3
No respiratory distress
Abd: Soft nondistended nontender
GU: 18F 3 way foley in place (placed by ED) no CBI running with
dark red drainage in bag Admission Date: [**2106-10-31**] Discharge Date: [**2106-11-15**]

Date of Birth: [**2028-12-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Sulfa (Sulfonamides) / Codeine / Ciprofloxacin / Penicillins

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Back Pain DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms. [**Known lastname **] is a 77 year-old female with osteoporosis DISEASE and multiple
vertebral compression fractures DISEASE status post vertebroplasty and
kyphoplasty last [**10-8**] by Dr. [**Last Name (STitle) 5730**] at [**Hospital1 2025**] (T10) also with
COPD DISEASE and bronchiectasis DISEASE on home oxygen 2L/min for 1 month and
chronic hyponatremia DISEASE secondary to SIADH who presents from home
with increasing back pain DISEASE .
*
She reports that she has baseline back discomfort from her
multiple previous interventions but has noted significant
worsening in the past 2 days bilateral with midline sparing
wrapping around to axilla bilaterally worse at the level of her
most recent surgery but also diffuse. She denies paresthesia DISEASE or
new extremity weakness DISEASE no difficulty urinating or defecating.
She denies fever DISEASE or chills DISEASE . On a different note she reports
chronic severe shortness of breath DISEASE stable over the past month
for which she uses 2L home oxygen. She denies phlegm DISEASE production
no chest pain DISEASE and endorses mild chronic LE edema DISEASE which has been
attributed to her Norvasc. She sleeps with multiple pillows due
to her kyphosis DISEASE and SOB no change recently.
*
In ED T 98.2 HR 76 BP 182/75 RR 24 Sat 100% on 2L/min. T
and L-spine X-rays did not reveal new fractures DISEASE CXR with
findings consistent with bronchiectasis DISEASE CT chest without PE but
with interval increase in bronchiectatic DISEASE and peribronchial
inflammatory changes. She was evaluated by neurosurgery deemed
to be intact neurologically. She is being admitted for ongoing
pain DISEASE control.


Past Medical History:
# chronic back pain compression fractures DISEASE
# COPD DISEASE with bronchiectasis DISEASE dx [**2080**]. [**2103**] with MYCOBACTERIUM
KANSASII and pseudomonas.
# hemorrhoids DISEASE
# hemorroidal prolapse DISEASE with GIB DISEASE
# SIADH
# perirectal abscess s/p I/D in [**3-7**]
# Pulmonary nodules
# Lower extremity edema DISEASE
# osteoporosis DISEASE
# mitral valve prolapse DISEASE
# spinal stenosis
# 1Admission Date: [**2133-5-12**] Discharge Date: [**2133-5-17**]

Date of Birth: Sex: M

Service:


HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old
male status post motor vehicle accident. The patient was a
restrained driver involved in a moderate speed motor vehicle
accident with prolonged extrication. Loss of consciousness DISEASE
was reported. The patient is currently complaining of left
shoulder pain DISEASE .

PAST MEDICAL HISTORY: Depression.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS: Wellbutrin Lexapro and Adderall.

PHYSICAL EXAMINATION: Temperature 98.8 heart rate 88 blood
pressure 130/83 respiratory rate 18 O2 saturation 100
percent on two liters. The patient is in no acute distress
with a GCS of 15. Pupils equal round and reactive to light.
The patient has a superficial left ear laceration and lip
laceration. Heart is regular rate and rhythm. Normal S1 and
S2. Chest is clear to auscultation bilaterally. Abdomen is
soft nondistended slightly tender in the left lower
quadrant with no guarding. Rectal examination is heme
negative with normal tone. Back is nontender with no
deformities DISEASE . Extremities show no deformities DISEASE two plus
dorsalis pedis pulses are palpated.

LABORATORY DATA: Hematocrit 43.4 normal chemistries normal
coagulation amylase 35 negative blood toxin screen urine
toxin screen positive for amphetamines lactate 2.3
urinalysis with moderate blood. Films performed include a
chest x-ray which showed a widened mediastinum. Pelvis x-ray
was negative. Head CT was negative. Neck CT was negative.
Chest CT showed a lingula contusion DISEASE and a single rib
fracture DISEASE . Abdomen and pelvic CT showed a small splenic
laceration. Left shoulder film was negative.

HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit at this time for close observation secondary to his
splenic laceration DISEASE . Serial hematocrit studies were performed
showing a persistently stable hematocrit and ruling out
enlargement DISEASE in the splenic laceration DISEASE . The patient was also
at that time placed on bed rest to prevent enlargement of his
splenic laceration DISEASE . Due to the apparent stability of his
splenic laceration DISEASE the patient was transferred to the floor
on hospital day two. On postoperative day three the patient
was restarted on oral nutrition which he tolerated well.
Physical Therapy consultation was obtained to ensure that the
patient did not have any residual deficits DISEASE . He passed
physical therapy with flying colors. Over the course of the
patient's stay however the patient became thrombocytopenic DISEASE .
The question arose if the patient had developed heparin
sensitive antibody to platelets. A heparin panel was sent
which was negative. The patient's platelet count did
stabilize. Due to his otherwise relative stability the
patient was discharged on [**2133-5-17**] in stable condition to
follow-up in the Trauma DISEASE Clinic in approximately two weeks. He
has been told he can resume normal activity resume a normal
diet and resume home medications. He is being sent home with
Percocet for pain DISEASE .



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**] [**MD Number(1) 5733**]

Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2133-7-13**] 12:09:49
T: [**2133-7-13**] 13:22:07
Job#: [**Job Number 5734**]
Admission Date: [**2145-5-6**] Discharge Date: [**2145-5-15**]


Service: Cardiothoracic Surgery

HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female
with a history of gastritis hypertension DISEASE and
hypercholesterolemia DISEASE who was admitted to the [**Hospital Unit Name 196**] Service on
[**2145-5-6**] for the complaint DISEASE of progressive chest pain DISEASE .
The patient described a two to three month history of
progressive shortness of breath and substernal chest pain DISEASE .
The patient stated that the chest pain DISEASE originally occurred at
rest and reported that her episodes had become more severe
over the ensuing time. The patient's episodes were
characterized by pain DISEASE radiating to both arms that would
occasionally wake her up at night and lasted approximately 30
minutes in duration. The patient was reportedly evaluated by
her primary care physician and was presumptively diagnosed
with gastritisAdmission Date: [**2153-6-20**] Discharge Date: [**2153-6-24**]

Date of Birth: [**2115-6-30**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Rifampin / Bactrim

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Fever DISEASE and SOB

Major Surgical or Invasive Procedure:
None

History of Present Illness:
37 year old male with advanced HIV resistent to many meds with
recent CD4 count of 140 and VL of 300000 up from 56000
presents with 2 1/2 weeks of symptoms. Began as a sore throat
and hacking cough DISEASE with fevers DISEASE over the past week. Fevers were
subjective. Cough worsened and caused tearing of the eyes and
occational emesis DISEASE . Patient denies hemoptysis DISEASE or change in
bowel habits (baseline diarrhea DISEASE ). He was unable to bring
anything up with his cough DISEASE . On evening prior to presentation
he developed night sweats that soaked his sheets and measured
his temp at 105. He was also feeling sob with walking up stairs
over the past day. Denies orthopnea.

In the ED presentation concerning for PCP. [**Name10 (NameIs) **] shows upper lobe
infiltrates bilat and patient has crackles and rales on exam.
Vitals on presentation were notable for temp of 105 HR 130s
hypoxia DISEASE stable BP 130/80. He was given tylenol flagyl
cefepime azithro prednisone nebs bactrim IV 4L NS. ID was
consulted re the bactrim as patient had a hemolytic anemia DISEASE in
the past that was thought to be due to bactrim though this was
never confirmed. Per PCP notes hct has been in the 40s most
recently. Patient improved but was brought to ICU for
monitoring of hct and pulm status.


Past Medical History:
HIV since late [**2127**] camplobacter diarrhea DISEASE TB exposure and INH
therapy for 1 year anal warts gonorrhea DM cellulitis DISEASE
[**Female First Name (un) **] PPD neg had suicide attempt many years ago using
tylenol overdose. Hemolytic anemia DISEASE [**2146**] (coombs Admission Date: [**2196-4-13**] Discharge Date: [**2196-4-19**]

Date of Birth: [**2127-10-25**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
asymptomatic

Major Surgical or Invasive Procedure:
[**4-13**] CABG x 3


History of Present Illness:
68 yo male with abnormal stress test as part of routine
physical referred for cardiac catheterization which showed 2
vessel disease DISEASE and he was referred for surgery.

Past Medical History:
PMH/PSH: Diabetes DISEASE diagnosed in [**2187**] Hyperlipidemia DISEASE Renal
calculi costochondritis S/P torsion DISEASE testicle with repair
Tonsillectomy

Social History:
quit tobacco 40 years ago
occasional etoh
lives with wife

Family History:
NC

Physical Exam:
HR 71 RR 17 BP 140/77
NAD
Lungs CTAB anteriorly
Heart RRR no M/R/G
Abdomen soft/NT/ND
Extrem warm no edema DISEASE


Pertinent Results:
CHEST (PORTABLE AP) [**2196-4-16**] 7:29 AM

CHEST (PORTABLE AP)

Reason: interval change

[**Hospital 93**] MEDICAL CONDITION:
68 year old man with s/p POD 3 CABG now RAF
REASON FOR THIS EXAMINATION:
interval change
PORTABLE CHEST ON [**2196-4-16**] AT 08:30

INDICATION: Post-op CABG.

COMPARISON: [**2196-4-15**].

FINDINGS: The right CVL has been removed and there is no
pneumothorax DISEASE . A previously visualized left PTX is not seen on
the current study. Left basilar atelectasis DISEASE and small effusion
remain. No new airspace disease DISEASE is seen.

IMPRESSION: No PTX after right CVL removal and no new airspace
disease.

[**2196-4-19**] 05:30AM BLOOD Hct-25.9*
[**2196-4-18**] 05:20AM BLOOD WBC-12.6* RBC-3.14* Hgb-9.5* Hct-28.2*
MCV-90 MCH-30.3 MCHC-33.7 RDW-14.5 Plt Ct-240
[**2196-4-19**] 05:30AM BLOOD PT-21.7* INR(PT)-2.1*
[**2196-4-18**] 05:20AM BLOOD PT-14.3* PTT-24.8 INR(PT)-1.2*
[**2196-4-15**] 02:03AM BLOOD PT-12.8 PTT-25.4 INR(PT)-1.1
[**2196-4-19**] 05:30AM BLOOD UreaN-30* Creat-1.0 K-4.2
[**2196-4-18**] 05:20AM BLOOD Glucose-102 UreaN-37* Creat-1.2 Na-140
K-4.4 Cl-103 HCO3-28 AnGap-13

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname 5738**] [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 5739**] (Complete)
Done [**2196-4-13**] at 2:33:55 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **] [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**] [**Numeric Identifier 718**] Status: Inpatient DOB: [**2127-10-25**]
Age (years): 68 M Hgt (in): 67
BP (mm Hg): 140/70 Wgt (lb): 176
HR (bpm): 65 BSA (m2): 1.92 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 786.05 786.51 440.0 413.9
Test Information
Date/Time: [**2196-4-13**] at 14:33 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**] MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**] MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: [**Pager number 5741**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension: 4.8 cm Admission Date: [**2188-1-14**] Discharge Date: [**2161-2-9**]

Date of Birth: [**2141-8-5**] Sex: F

Service:

ADMISSION DIAGNOSIS: Unstable angina DISEASE .

DISCHARGE DIAGNOSIS:
1. Coronary artery disease DISEASE .
2. Status post coronary artery bypass graft times two.

HISTORY OF THE PRESENT ILLNESS: The patient is a 46-year-old
woman with a history of chest pain DISEASE and positive stress test
who is referred for cardiac catheterization. Previously to
this she has had chest pain DISEASE approximately once a month with
increasing frequency to approximately one to two times per
week. The pain DISEASE is substernal chest pressure associated with
left arm pain DISEASE . It usually occurs at rest and lasts between
three to 30 minutes. No associated shortness of breath DISEASE .
Positive for dyspnea DISEASE on exertion.

The patient had a positive ETT as well as a positive stress
echocardiogram. She had cardiac catheterization performed on
[**2188-1-11**] which revealed an ejection fraction of 60% right
dominant coronary artery system and 70% stenosis of the left
main. The patient presents for revascularization.

PAST MEDICAL HISTORY:
1. Thirty pack year smoking history.
2. Hypercholesterolemia DISEASE .
3. Renal insufficiency DISEASE in the past.
4. Bilateral reimplantation of the ureters at age ten.
5. Cesarean section times two.
6. Pilonidal cyst.
7. Tonsillectomy.

ALLERGIES: The patient is allergic DISEASE to sulfa and shrimp. No
allergy DISEASE to dye.

ADMISSION MEDICATIONS:
1. Lipitor 20 mg q.d.
2. Atenolol 50 mg q.d.
3. Wellbutrin 300 mg q.d.
4. Zoloft 100 mg q.d.
5. Multivitamin q.d.
6. Aspirin q.d.

PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
a middle-aged woman in no acute distress. HEENT:
Normocephalic atraumatic. PERRL EOMI anicteric. The
throat was clear. The neck was supple and midline without
masses or lymphadenopathy DISEASE . Chest: Clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm
without murmurs rubs or gallops. Abdomen: Soft
nontender nondistended without masses or organomegaly DISEASE .
Extremities: Warm noncyanotic nonedematous times four.
Neurological: Grossly intact.

LABORATORY DATA ON ADMISSION: CBC 11.8/14.2/40.7/193. INR
1.0. Chemistries 143/4.3/105/33/10/0.6.

HOSPITAL COURSE: The patient had coronary artery bypass
graft times two on [**2188-1-15**]. The patient tolerated the
procedure well and was transferred to the Intensive Care Unit
on a propofol drip. The patient was extubated without
incident on postoperative day number one. She was also
maintained on a Neo drip for labile blood pressures.

The patient was incredibly anxious and called out with any
procedure as small as tape removal. She was much more
cooperative after Ativan was begun.

On postoperative day number one the patient was transfused 1
unit of packed red blood cells for a hematocrit of 23. Post
transfusion the hematocrit was 27. Unable to wean Neo at
that time.

On postoperative day number two the patient remained A paced
with an underlying rhythm in the 70s to keep systolic blood
pressure greater than 90. Neo was weaned down and eventually
to off. Physical Therapy began work with the patient.

On postoperative day number three the patient was
transferred to the floor without incident. On the floor she
continued to do well and diuresed off quite a bit of fluid.
In addition she continued to work with Physical Therapy.
The patient was cleared for discharge home on postoperative
day number five.

On postoperative day number five the patient was discharged
to home tolerating a regular diet and adequate pain DISEASE control
on p.o. pain DISEASE medications and having had the chest tubes and
wires discontinued.

PHYSICAL EXAMINATION ON DISCHARGE: The patient is a
middle-aged woman who is intermittently quite anxious. The
vital signs were stable afebrile. The heart revealed a
regular rate and rhythm without murmurs rubs or gallops.
The chest was clear to auscultation bilaterally. There was
no sternal click and no sternal drainage. The patient does
have 1Admission Date: [**2149-11-16**] Discharge Date: [**2149-11-20**]

Date of Birth: [**2074-6-23**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Ibuprofen

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Right coronary artery ST-elevation myocardial infarction DISEASE

Major Surgical or Invasive Procedure:
Cardiac catheterization

History of Present Illness:
Patient reports she was [**Location (un) 1131**] a book at 1500h at home today
and had sudden onset bilateral arm pain DISEASE and heaviness DISEASE from the
biceps to the lower arms and chest pain DISEASE . Per telephone triage
she also had wheezing DISEASE and was very anxious. She had never had
chest pain DISEASE like this before. She was sent to the ED and recieved
325mg of ASA and Morphine 10mg IV prior to arrival. She received
Oxygen Plavix 600mg heparin bolus 4200u IV and integrillin
bolus 12mg IV. EKG demonstrated STE in II III AvF as well as
in Right sided leads V3-V6 concerning for inferior infarct DISEASE and
RCA occlusion DISEASE . Paatient was taken to cath lab and underwent PTCA
with deployment of three BMS in the proximal RCA. She tolerated
the procedure well and was admitted to the CCU for
post-operative care.
.
Cardiac review of systems is notable for absence of chest pain DISEASE
dyspnea DISEASE on exertion


Past Medical History:
ONCOLOGIC HISTORY: Initially presented with URI-symptoms in
[**2144-9-17**]. CXR followed by CT scan showed adenopathy DISEASE and
bronchial collapse DISEASE and a large hilar mass. Transbronchial
needle aspiration and biopsy showed SCLC DISEASE . She was treated with
carboplatin and etoposide with radiation for a total of 4Admission Date: [**2145-12-12**] Discharge Date: [**2145-12-17**]

Date of Birth: [**2075-9-16**] Sex: M

Service: [**Hospital1 139**] Firm

HISTORY OF PRESENT ILLNESS: This is a 70-year-old man with
history of recurrent transitional cell carcinoma DISEASE of the
bladder anemia DISEASE and questionable celiac sprue DISEASE who presented
with weakness DISEASE and pallor DISEASE of [**1-31**] weeks duration followed by
decreased hematocrit and increased INR to the MICU. In
[**2145-8-30**] the patient had a high retrograde urethral
catheter placed for BCG for recurrent transitional cell
carcinoma DISEASE in his right renal pelvis. He had a right
nephrostomy tube placed in [**9-30**]. He was treated every weekAdmission Date: [**2174-5-29**] Discharge Date: [**2174-6-9**]

Date of Birth: [**2093-11-17**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Atorvastatin

Attending:[**First Name3 (LF) 134**]
Chief Complaint:
cough DISEASE SOB

Major Surgical or Invasive Procedure:
RIJ placed
Hemodialysis


History of Present Illness:
Pt is an 80F with a history of severe AS CAD s/p nephrectomy
for RCC DISEASE with ESRD DISEASE recently started on HD DISEASE and recent admission to
[**Hospital1 18**] for cough DISEASE [**Date range (1) 135**] p/w cough DISEASE . Today she woke up from
sleep with acute shortness of breath and cough DISEASE . NO Chest pain DISEASE .
Husband called 911. In the ER afebrile HR 120s SBP 110s. CXR
with Admission Date: [**2162-9-20**] Discharge Date: [**2162-9-27**]

Date of Birth: [**2089-12-21**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Neomycin

Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
fever DISEASE altered mental status

Major Surgical or Invasive Procedure:
none


History of Present Illness:
72yo F quadriplegic DISEASE with chronic indwelling foley presented
from [**Hospital1 1501**] to [**Hospital1 18**] ED via EMS on [**2162-9-20**] w/ decreased mental
status cloudy urine fever DISEASE and hypotension DISEASE .
.
In the ER her SBP dropped quickly from 100 to 60s and code
sepsis DISEASE called. She was noted to have milky white urine coming
from her indwelling foley catheter. Her foley catheter was then
changed and she was started on IV abx - zosyn (despite report of
vague allergy DISEASE ) and linezolid. She initially required pressors
for blood pressure control.
.
Early in the [**Hospital Unit Name 153**] course pt was weaned off pressors. Blood cx's
returned with pan sensitive e. coli. Urine culture at present is
grown two separate GNR's and decision was made to continue with
double GNR coverage (Zosyn and levofloxacin) out of concern for
possible reistant pseudomonas. Other complication early in
course of [**Hospital Unit Name 153**] stay included reanl failure DISEASE which is responding
well to re-hydration. Pt also complained of a headache DISEASE in the
[**Hospital Unit Name 153**]. CT of head was without acute findings and headache DISEASE
responded fully to tylenol therefore no further work up was
pursued by the [**Hospital Unit Name 153**] team.
.
On arrival to floor pt denies any complaints.

Past Medical History:
# C4 quadriplegic DISEASE s/p fall [**5-21**]
# hiatal hernia DISEASE
# HTN DISEASE
# h/o decubitus ulcers DISEASE
# diverticulitis DISEASE
# recurrent UTI DISEASE from indwelling foley catheter -Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]

Date of Birth: [**2073-10-17**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea DISEASE on Exertion with abnormal stress test

Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA-Admission Date: [**2192-10-1**] Discharge Date: [**2192-10-3**]

Date of Birth: [**2128-11-19**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
melena chest pain DISEASE .

Major Surgical or Invasive Procedure:
EGD [**2192-10-2**].

History of Present Illness:
63M with history of HTN DISEASE and Hypercholesterolemia DISEASE presents with a
one-week history of melena DISEASE and chest pain DISEASE .
.
The patient underwent a Colonoscopy and EGD on [**2192-9-24**] after he
was found to be guaiac positive by his PCP in early [**Month (only) 359**].
Colonoscopy showed diverticulosis DISEASE of the sigmoid colon and
proximal ascending colon. EGD revealed a polyp DISEASE in the pylorus
and a polyp DISEASE in the second part of the duodenum both of which
were biopsied. The procedure was uncomplicated and the patient
was discharged home. Two days later he developed black tarry
stools approximately two episodes per day for five days. Over
this time he also developed [**2197-2-20**] substernal chest pressure
associated with climbing stairs and walking on an incline and
relieved with rest. The pain DISEASE was non-radiating DISEASE and associated
with SOB and dizziness DISEASE but not N/V diaphoresis DISEASE or
palpitations DISEASE . He went to church on the day prior to admission
and was walking with a friend who is a nurse who told him that
he looked pale and that he should see a doctor. He had an
additional episode of chest pain DISEASE and melena DISEASE and decided to
present to the ED.
.
In the ED the patient was hemodynamically stable with BP 129/60
and HR 80. His cardiac enzymes were positive and he was given an
ASA and the plan was admission to [**Hospital Unit Name 196**]. His hct returned at 23.6
(down from 44 in [**Month (only) 359**]) and he had guaiac positive stool. He
was admitted to the MICU for observation.


Past Medical History:
1. HTN DISEASE
2. Hypercholesterolemia DISEASE
3. s/p Hernia Repair
4. Stress test Admission Date: [**2194-6-5**] Discharge Date: [**2194-6-15**]

Date of Birth: [**2128-11-19**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Codeine / Plavix / Aspirin

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
exertional angina DISEASE and positive ETT

Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2194-6-5**]
Coronary Artery Bypass Grafting x4 [**2194-6-9**] (LIMA to LAD SVG to
DIAG SVG to OM SVG to PDA)

History of Present Illness:
65 y/o M with PMH of HTN DISEASE CAD hyperlipidemia DISEASE and chronic
thrombocytopenia DISEASE who initially presented to the CMI service [**6-5**]
for elective cardiac cath. The patient had complained to his PCP
of exertional substernal chest pain DISEASE for the past two weeks. He
describes the pain DISEASE as occurring when he does heavy lifting or
otherwise exerts himself and resolving with rest.
.
He underwent an outpatient stress-ECHO which showed apical
septal dyskinesis post-exercise indicating ischemia DISEASE . The LVEF
was reported as 70%. He presneted for elective admission and
underwent cardiac cath on [**6-5**] that showed the LMCA had a distal
30% stenosis. The LAD had a calcified 50% ostial stenosis DISEASE and
80% serial mid stenoses. The LCX DISEASE had no angiographically
apparent disease. The OM1 had a 50% stenosis. The RCA had a 50%
proximal and a 70% distal stenosis. With these findings it was
decided to proceed with CABG. Given his severe LAD disease DISEASE he
was started on heparin gtt to be continued until surgery could
be performed. Given that the patient had received loading dose
of plavix CABG will not occur until [**6-9**]. He is currently chest
pain DISEASE free.


Past Medical History:
1. hypertension DISEASE
2. Hypercholesterolemia DISEASE
3. s/p Hernia Repair
4. Stress test Admission Date: [**2157-11-20**] Discharge Date: [**2157-11-25**]


Service: MEDICINE

Allergies DISEASE :
lisinopril

Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
shortness of breath DISEASE

Major Surgical or Invasive Procedure:
[**2157-11-20**] endotracheal intubation


History of Present Illness:
Mr. [**Known lastname **] is an 88 yo M with h/o dCHF COPD DM2 CKD DISEASE presents
with acute shortness of breath DISEASE .
.
Per family patient had become increasingly short of breath at
home over the last few days. This morning he felt so short of
breath that he insisted on coming to the ED. Also complaining
of burning chest pain DISEASE . Has been taking meds as prescribed
reports Admission Date: [**2118-9-23**] Discharge Date: [**2118-9-30**]

Date of Birth: [**2039-1-10**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Low energy cough DISEASE


Major Surgical or Invasive Procedure:
expired


History of Present Illness:
79yoM with prior MI s/p PTCA VT/VF DISEASE s/p ablation sCHF (last EF
23% in [**2110**]) presenting with low energy fatigue DISEASE abdominal
discomfort.

The patient reported progressively worsening fatigue DISEASE and
lethargy DISEASE for the past 4 months associated with nausea DISEASE . He also
reports a progressive dry cough DISEASE during that time period but
denies sputum production fevers shortness of breath DISEASE or sick
contacts. [**Name (NI) **] does report sinus pressure but denies headaches DISEASE
rhinorrhea DISEASE or sore DISEASE throat. Per ED report he had endorsed
abdominal discomfort with belching DISEASE but the patient currently
denies this history. He also endorses increased significant
water intake recently with increased pedal edema DISEASE . His
cardiologist reports increased facial edema DISEASE as well.

Of note the patient has had difficulty with his gait for the
past 6 months which is documented in OMR. His primary care
physician was concerned for Parkinsonian symptoms DISEASE given his
facial expression gait imbalance and midl tremor DISEASE . The patient
had declined neurological evaluation per OMR notes.

On review of systems the patient denies headache DISEASE vision
changes confusion DISEASE or somnolence sore DISEASE throat sputum
production rhinorrhea shortness DISEASE of breath chest pain emesis DISEASE
abdominal pain diarrhea dysuria polyuria DISEASE new or unusual
myalgias DISEASE or arthralgias DISEASE or rash DISEASE . He does report he was
constipated DISEASE last week and took an enema with improvement of his
symptoms. His last BM was reportedly yesterday and he denies
BRBPR or melena DISEASE .

In the ED initial VS were: 97 127 151/117 20 95% 3L.
Sodium was discovered to be 115 and the patient was given NS
700cc total. Head CT showed no evident cerebral edema DISEASE . CXR
showed L lobe infiltrate with a round area in the center of
lucency concerning for possible cavitation DISEASE with radiology
recommendation of further evaluation w/ CT scan given concern
for abscess DISEASE . He received Levofloxacin 750mg Ceftriaxone 1gm
Azithromycin 500mg (for Legionella coverage). He was noted to
be in new onset a fib with RVR and was given in the diltiazem
10 mg IV x2 and 30 mg p.o. for rate control with good effect.
He was admitted to the MICU for the degree of hyponatremia DISEASE .
Subsequent VS prior to transfer was: 134/116 and subsequently
109/76 89 24 94% 3L
.
On arrival to the MICU the patient denied symptoms other than
fatigue DISEASE including chest pain shortness DISEASE of breath confusion DISEASE
abdominal pain nausea DISEASE .
.
Review of systems:
(Admission Date: [**2102-7-27**] Discharge Date: [**2102-7-29**]

Date of Birth: [**2063-8-23**] Sex: F

Service: MEDICINE

Allergies DISEASE :
IodineAdmission Date: [**2103-12-21**] Discharge Date: [**2103-12-23**]

Date of Birth: [**2063-8-23**] Sex: F

Service: MEDICINE

Allergies DISEASE :
IodineAdmission Date: [**2195-3-23**] Discharge Date: [**2195-4-1**]

Date of Birth: [**2112-12-21**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea DISEASE on exertion

Major Surgical or Invasive Procedure:
[**2195-3-23**] Aortic Valve Replacement(25mm Mosaic Porcine Valve)
Mitral Valve Replacement(29mm Mosaic Porcine Valve) Replacement
of Ascending Aorta(26mm Gelweave) and Atrial Myxoma DISEASE Removal


History of Present Illness:
Mr. [**Known lastname 5784**] is an 81 year old male with known atrial fibrillation DISEASE
and atrial myxoma DISEASE for approximately 9 years. Serial
echocardiograms have revealed worsening aortic insufficiency DISEASE and
mitral regurgitation DISEASE . He concomitantly has complained of
progressive dyspnea DISEASE on exertion [**1-3**] pillow orthopnea and
worsening cough DISEASE . Cardiac catheterization in [**2194-5-31**] showed
normal coronary arteries and an LVEF of 50%. A transesophogeal
echocardiogram in [**2194-10-31**] confirmed 3Admission Date: [**2195-4-4**] Discharge Date: [**2195-4-16**]

Date of Birth: [**2112-12-21**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Pleural effusion/Pericardial effusion

Major Surgical or Invasive Procedure:
[**2195-4-7**] - Mediastinal exploration and mediastinal
hematoma DISEASE evacuation.


History of Present Illness:
This 82-year-old gentleman with known atrial fibrillation DISEASE and an
atrial myxoma DISEASE who underwent serial echocardiograms that have
revealed worsening aortic
insufficiency DISEASE and mitral regurgitation DISEASE . Based on these findings
he underwent an aortic valve replacement as well as mitral valve
replacement and atrial myxoma DISEASE excision. This was performed on
[**2195-3-23**]. He was discharged home and while he was in a hotel
where he was staying several days after he was discharged he
had a syncopal DISEASE episode. During the syncopal DISEASE episode the family
dialed 911 the patient was hypotensive DISEASE w/respiratory distress
and was intubated. A large left pleural effusion DISEASE was drained for
1400 cc serosanguinous
fluid. After the patient was hemodynamically stabilized he was
transferred to [**Hospital1 18**]. he underwent an echocardiogram which
revealed a large mediastinal hematoma DISEASE with some signs of early
tamponade. Based on these findings it was decided to take the
patient back to the operating room .

Past Medical History:
Congestive Heart Failure(diastolic) Aortic Insufficiency
Mitral Regurgitation Atrial Myxoma Dilated DISEASE Ascending Aorta
Atrial Fibrillation Hypertension Hyperlipidemia DISEASE Benign
Prostatic Hypertrophy Sleep Apnea DISEASE - on CPAP Obesity

Social History:
Retired lives with wife in [**Name (NI) 108**]. Quit cigars over 10 years
ago. Admits to social ETOH consumption.


Family History:
Denies premature coronary disease(before age 55)

Physical Exam:
Admission
94 139/80 100% on Vent
WDWN man intubated and sedated
Irregular rate and rhythm
Obese NT/ND DISEASE NABS Triple lume in groin
EXT: 2Admission Date: [**2188-11-1**] Discharge Date: [**2188-11-8**]


Service: Medicine [**Hospital1 139**]

HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female who has a past medical history significant for
coronary artery disease hypertension dementia DISEASE recurrent
pneumonia DISEASE and recent gastrectomy for peptic ulcer disease DISEASE
who presented to the emergency room with a complaint DISEASE of
increasing shortness of breath DISEASE . The patient had been at home
for approximately 2 days following discharge from rehab
following gastrectomy when shortness of breath DISEASE developed.
Emergency medical services were called and the patient was
found to have an oxygen saturation of 65% on room air and 85%
on 100% non-re-breather.

PAST MEDICAL HISTORY:
1. Hypothyroid.
2. Coronary artery disease.
3. Hypertension DISEASE .
4. Peptic ulcer disease status post gastrectomy for
perforated ulcer DISEASE .
5. Dementia.
6. Esophageal motility disorder.
7. Recurrent pneumonia DISEASE .

SOCIAL HISTORY: Living situation - the patient at baseline
resides at home with 24 hour home health assistance. There
is extensive family involvement. The patient's code status
is DNR DNI.

FAMILY HISTORY: Noncontributory.

ALLERGIES: Sulfa.

MEDICATIONS:
1. Aricept 10 mg.
2. Lasix 40 mg.
3. Prevacid 30 mg.
4. Lopressor 25 mg b.i.d.
5. Multi-vitamin.
6. Effexor 70 mg.
7. Prednisone 25 mg.
8. Zofran p.r.n.
9. Synthroid 15 mg.

EXAM DISEASE : On presentation to the emergency department the
patient was found to have vital signs as follows:
Temperature 98.7 heart rate 82 blood pressure 160/62
respiratory rate 25 oxygen saturation 87% on room air. In
general the patient is a well nourished but thin female in
respiratory distress DISEASE . There was no jugular venous distention DISEASE
on examination of the neck. Lung exam revealed decreased
breath sounds bilaterally. Cardiovascular exam was
unremarkable. The PEG site was clean dry and intact. The
patient was alert and oriented only to person.

LABORATORY STUDIES: Admission CBC was unremarkable.
Admission SMA-7 was significant for an elevated BUN to
creatinine ratio consistent with dehydration DISEASE . Urinalysis was
unremarkable. Cardiac enzymes were significant for an
isolated elevated troponin. Coagulation studies were
unremarkable. Arterial blood gas on 100% oxygen was
significant for a decreased pO2 of 70 and an elevated pCO2 of
59 with a normal pH.

RADIOLOGY: Chest x-ray on admission revealed mild congestive
heart failure DISEASE markedly improved since the prior study of
[**2188-8-17**]. There was also bilateral lower lobe
opacification concerning for pneumonia DISEASE . CT angiogram
revealed consolidations at both lung bases consistent with
bibasilar pneumonia DISEASE as well as subtle patchy opacifications
in the upper lobes with air fluid levels in the esophagus
suggesting possible aspiration. There was no evidence of
pulmonary embolism DISEASE .

CARDIAC STUDIES: EKG on admission revealed sinus rhythm with
mild left axis deviation. There was also felt to be possible
left anterior fascicular block. The admitting MICU team
noted possible ST elevations in V3 through V6.
Echocardiogram revealed mild symmetric left ventricular
hypertrophy DISEASE with normal left ventricular cavity size.
Overall left ventricular systolic function was normal. There
was normal right ventricular systolic function. There was
also moderate aortic regurgitation DISEASE . No pericardial effusion DISEASE .

HOSPITAL COURSE:
1. Respiratory distress DISEASE : On admission the patient was felt
to have bilateral pneumonia DISEASE most likely secondary to
aspiration. The patient was started on IV Levaquin Flagyl
and Vancomycin to cover for likely aspiration in a setting of
recent nursing home admission. The patient was kept on
supplemental oxygen to keep oxygen saturations above 92% and
was kept NPO on aspirations precautions. On day of admission
antibiotics were changed to IV ceftazidine Flagyl DISEASE and
Vancomycin. Vancomycin was dosed at 1 gram q24 hours in the
setting of patient's decreased renal function age and body
size. On day two of admission the patient was also felt to
be fluid over loaded and gentle diuresis was resumed. On day
two of admission the patient was felt to be stable for
transfer to the floor. On the floor the patient was
initially continued on IV antibiotics. On day five of
admission the patient had a follow up chest x-ray which
revealed marked improvement in bibasilar pneumonia DISEASE . The
patient also had improvement in oxygen saturation and was
able to tolerate room air. As a result the patient was
transitioned to p.o. antibiotics and was given Augmentin and
Flagyl through the PEG tube. The patient was discharged home
on hospital day 9 with instructions to complete a 14 day
course of p.o. antibiotics for presumed aspiration pneumonia DISEASE .

2. Cardiovascular: Elevated troponin as well as possible ST
elevations on admission were felt to reflect a demand
ischemia DISEASE . Cardiac enzymes and EKG changes stabilized. The
patient was continued on aspirin Lopressor throughout the
admission. On day three of admission the patient had an
episode of sinus tachycardia DISEASE likely secondary to dehydration DISEASE
versus multi-focal atrial tachycardia DISEASE secondary to pulmonary
disease. This resolved following hydration. The patient's
cardiovascular function remained stable for the rest of the
admission.

3. Dementia: The patient was continued on Aricept
throughout the admission.

4. Gastrointestinal: Following rehydration the patient was
found to have a mildly decreased hematocrit. As a result
the patient was received an elevation by gastroenterology to
look for gastrointestinal bleeding DISEASE as an etiology of
decreased hematocrit. Given the patient's history of peptic
ulcer disease DISEASE gastroenterology service recommended H. pylori
serology which was negative. Iron studies were sent which
revealed a decreased total iron binding capacity as well as
decreased iron suggestive of a combination of both blood loss DISEASE
and chronic disease DISEASE as etiologies of anemia DISEASE .
Gastroenterology service felt however that EGD and
colonoscopy were not an option in setting of patient's recent
ischemic cardiac disease DISEASE . Furthermore the patient refused
gastroenterology work up. Gastroenterology service also
asked to evaluate patient for possible contribution of reflux
of jejunostomy tube feedings to development of aspiration
pneumonia DISEASE . Gastroenterology service felt that reflux of
J-tube feedings was unlikely however felt that patient's
long history of esophageal dysmotility DISEASE could be contributing
to aspiration. They recommended swallowing study. The
patient received an oropharyngeal video fluoroscopic
swallowing evaluation on day five of admission. This
revealed mild oral with moderate to severe pharyngoesophageal
dysphagia DISEASE with significant impaired upper esophageal sphincter DISEASE opening leading to severe residue of solids in the
pharynx. However there was no aspiration. Nevertheless
swallowing service recommended the patient in future have
only thin liquids pureed solids or very finely/minced meat
in p.o. diet. They also recommended that the patient sit
bolt upright at meals and for 45 minutes after meals. They
recommended the patient remain at 45 degrees in bed at all
times and should never lay flat in bed and recommended that
if patient must remain flat in bed that tube feedings be
discontinued for 30 minutes prior to patient laying flat in
bed.

5. Endocrine: The patient was continued on Levothyroxine
for hypothyroidism DISEASE .

6. GU: The patient was placed on Foley catheter on
admission to the hospital. On day seven of admission the
patient was ready for discharge from a medical standpoint
but did not void in time status post discontinuation of the
Foley catheter. As a result the patient remained in-house
for an additional day to ensure the patient could void
spontaneously following discontinuation of Foley catheter.

POST DISCHARGE MEDICATIONS: Metronidazole 500 mg q8 hours x7
days Augmentin 500/125 mg p.o. b.i.d. x7 days furosemide 40
mg p.o. q.d. aspirin 325 mg p.o. q.d. metoprolol 25 mg p.o.
b.i.d. Venlafaxine HCL 75 mg capsule p.o. q.d.
Levothyroxine 150 mcg p.o. q.d. donepezile hydrochloride 10
mg p.o. q.h.s. Lansoprazole 30 mg q.d. iron sulfate 325 mg
p.o. q.d. multi-vitamin.

DISPOSITION: To home with visiting nurse as well as 24 hour
home health assistance.

DISCHARGE STATUS: On day of discharge the patient was
ambulating voiding spontaneously and had oxygen saturation
of 97% on two liters. The patient was demented in a manner
consistent with baseline.

DISCHARGE DIAGNOSES:
1. Aspiration pneumonia DISEASE .
2. Coronary artery disease DISEASE .
3. Hypertension DISEASE .
4. Peptic ulcer disease status post gastrectomy.
5. Hypothyroidism.
6. Dementia.
7. Esophageal dysmotility.
8. Dehydration.

CODE STATUS: DNR and DNI.

RECOMMENDED FOLLOW UP: Follow up with Dr. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**]
[**Telephone/Fax (1) 142**] if new problems arise.






[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**] M.D. [**MD Number(1) 144**]

Dictated By:[**Last Name (NamePattern1) 145**]

MEDQUIST36

D: [**2188-12-13**] 16:12
T: [**2188-12-15**] 06:37
JOB#: [**Job Number 146**]
Admission Date: [**2195-5-27**] Discharge Date: [**2195-6-4**]

Date of Birth: [**2112-12-21**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Recurrent left lower lobe effusion

Major Surgical or Invasive Procedure:
Flexible bronchoscopy decortication and parietal
pleurectomy diaphragmatic plication.


History of Present Illness:
Mr. [**Known lastname 5784**] is an 82 year-old male s/p AVR/MVR DISEASE (pericardial)
right atrial myxoma DISEASE resection AsAo graft [**3-7**] chronic atrial
fibrillation DISEASE who has had a left-sided pleural effusion DISEASE and
marked dyspnea DISEASE since a cardiac operation. He appears to have a
fluid collection most recently which was not accessible by
ultrasound-guided thoracentesis.


Past Medical History:
Left pleural Effusion
Atrial Fibrillation DISEASE
Diastolic heart failure DISEASE (EF 45%)
Hypertension DISEASE
Obstructive sleep apnea DISEASE on CPAP
GERD
[**Month/Year (2) 5783**]
[**3-7**] Resection of Right atrial myxoma AVR/MVR DISEASE (pericardialAdmission Date: [**2117-8-9**] Discharge Date: [**2117-8-30**]

Date of Birth: [**2042-9-7**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Albuterol

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Nausea DISEASE and vomiting DISEASE

Major Surgical or Invasive Procedure:
Paracentesis

History of Present Illness:
Ms. [**Known lastname 5796**] is a 74 yo G3P3 scheduled for TAH/BSO debulking on
[**8-10**]
presenting to the ED with N/V DISEASE after initiating her bowel prep
yesterday. She used approximately 1.5 of the 3 bottles of prep
and since then has had continuous N/V of brown coffee-grounds DISEASE
emesis DISEASE . She also reports diarrhea DISEASE per the bowel prep but denies
any blood in her stoolAdmission Date: [**2170-5-7**] Discharge Date: [**2170-5-10**]

Date of Birth: [**2140-6-19**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
Toxic ingestion in suicide attempt

Major Surgical or Invasive Procedure:
Intubated and extubated

History of Present Illness:
29 yo male with h/o depression DISEASE and ADHD DISEASE who presented to ED with
ingestion of Nyquil and ibuprofen in suicide attempt. Patient
notes history of depression DISEASE secondary to recent death DISEASE of sister
and not taking his Paxil for past 2 months. Pt was on Mass
Health but did not complete forms and lost coverage 2 months ago
so had no way to pay for Paxil. Per pt's mother on night of
admission pt called her to tell her he took some pills. He
drove to her house and she found him to be lethargic. In ED
given Narcan DISEASE with no result. Pt intubated for airway protection
with dose of vercuronium for agitation DISEASE . Pt given 1.2 grams of
N-acetylcysteine and activated charcoal x1. EKG showed ST at
106 normal axis normal intervals TWI in III AVF. Pt had mild
transaminitis DISEASE . Toxicology was consulted and recommended
supportive care including follow LFT's and re-checking EKG. Tox
screen was only pos for amphetamines.

Past Medical History:
Depression DISEASE -no previous psychiatric DISEASE admission (PCP-[**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**]
prescribes paxil)
ADHD DISEASE

Social History:
Lives with roommate in [**Location (un) 745**]. Plays piano gives lessons.
Sister died 2-3 months ago from crack overdose DISEASE . No ETOH or drug
use.

Family History:
Admission Date: [**2177-5-14**] Discharge Date: [**2177-5-17**]

Date of Birth: [**2146-7-21**] Sex: F

Service: SURGERY

Allergies DISEASE :
Dilaudid DISEASE

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ventral hernia DISEASE

Major Surgical or Invasive Procedure:
umbilical and ventral hernia DISEASE repair

History of Present Illness:
30yo female currently on HD DISEASE had PD DISEASE catheter removed in [**Month (only) 116**]
[**2176**] with ongoing complaint DISEASE of pain DISEASE from an umbilical hernia DISEASE .

Past Medical History:
- ESRD DISEASE since [**2174-8-29**] currently on HD via tunneled line
- Peritonitis DISEASE [**8-7**]
- Type I DM complicated by neuropathy DISEASE and nephropathy DISEASE
- Bilateral cataract DISEASE surgeries
- Ventral Hernia


Social History:
- Lives with her mother Admission Date: [**2177-6-20**] Discharge Date: [**2177-6-26**]

Date of Birth: [**2146-7-21**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Dilaudid / Iodine-Iodine Containing

Attending:[**First Name3 (LF) 5806**]
Chief Complaint:
Chief Complaint: Headache
Reason for ICU Admission: Monitoring after contrast allergic DISEASE
reaction

Major Surgical or Invasive Procedure:
None


History of Present Illness:
History of Present Illness:
Ms. [**Known lastname **] is a 30 year old lady on HD DISEASE (previously PD DISEASE until
[**4-/2177**]) for ESRD DISEASE secondary to type 1 DM for the past 3 years.
Per her mother with whom she lives she developed a headache DISEASE
hypoglycemia nausea DISEASE and vomiting DISEASE and abdominal pain DISEASE with chills DISEASE
over the past day. She was also more combative and somnolent at
home. She did have HD DISEASE on Thursday as scheduled and per a
nephrology census note has a history of catheter infections DISEASE .
She was brought in by ambulance to the [**Hospital1 18**] for further
evaluation.
.
In the ED initial vs were: 100.4 90 [**Telephone/Fax (2) 5809**]. Patient
underwent LP after receiving Vanc CTX and acyclovir and blood
cultures. CSF unrevealing. The patient also underwent Head CT
and CXR. She was slated for CT Ab/Pelvis with IV contrast to
evaluate her abdominal pain DISEASE given her recent hernia DISEASE repair
(despite her mother's protestations) and during the contrast
exposure developed rapid facial swelling oropharyngeal rash DISEASE
without wheezing DISEASE or hives. She was given Solumedrol
Famotidine Benadryl and 1L NS for allergic reaction DISEASE and
transferred to the ICU for further monitoring. CT Ab with PO
contrast was obtained prior to transfer. Renal was consulted. VS
ib transfer: 87 199/93 14 100% RA- no headache DISEASE or chest pain DISEASE .
.
On the floor the patient is somonolent but arousable. She is
tacitly refusing to answer questions but does respond to
commands and express her displeasure at my attempt to interview
her. A brief meeting with her mother confirmed the story above.
.
Review of systems: Unable to obtain


Past Medical History:
Past Medical History:
- ESRD DISEASE since [**2174-8-29**] HD through L IJ Tunnelled line
- Peritonitis DISEASE [**8-7**]
- Type I DM complicated by neuropathy DISEASE and nephropathy DISEASE
- Bilateral cataract DISEASE surgeries
- Ventral Hernia repaired [**4-/2177**]

Social History:
- Lives with her mother Admission Date: [**2177-7-1**] Discharge Date: [**2177-7-3**]

Date of Birth: [**2146-7-21**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Dilaudid / Iodine-Iodine Containing

Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
tachypnea hypoxia DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
30 YO F w ESRD DISEASE [**12-31**] DM1 DISEASE on HD DISEASE M/W/F s/p recent admission for
contrast allergy DISEASE who presented with SOB after missing her HD DISEASE
session yest. Went to HD DISEASE today but was found to be tachypneic DISEASE to
the 30s w bibasilar rales DISEASE . EMS gave 15L NRB 97%. Upon arrival
the patient was 88% on RA DISEASE . Exam was notable for bibasilar
crackles. She was started on BiPap and given 80IV lasix and
nitro paste Ca gluconate for peaked T-waves 20u regular
insulin. Renal was contact[**Name (NI) **] and plan to do HD when she arrives
to the MICU.
.
Upon arrival to the MICU the patient reports improved SOB with
the Bipap mask. She was noted by nursing to have an episode of
rigors DISEASE without fever DISEASE .
.
Review of sytems:
(Admission Date: [**2140-3-15**] Discharge Date: [**2140-3-18**]

Date of Birth: [**2082-7-23**] Sex: M

Service: CCU

CHIEF COMPLAINT: Chest pain DISEASE .

HISTORY OF PRESENT ILLNESS: This is a 57 year old male with
hypercholesterolemia DISEASE and known coronary artery disease DISEASE status
post coronary artery bypass graft in [**2130**] with quiescent
disease since then not requiring sublingual NitroglycerinAdmission Date: [**2167-8-27**] Discharge Date: [**2167-9-2**]

Date of Birth: [**2092-2-10**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 75 year-old
female who was initially admitted to the Coronary Care Unit
and then transferred to the [**Hospital Unit Name 196**] Service. She has a history
of chronic atrial fibrillation congestive heart failure DISEASE
mitral regurgitation hypertension BOOP DISEASE and status post
recent left hip fracture DISEASE repair. The patient presented with
persistent worsening of shortness of breath DISEASE . In the
Emergency Department the patient was noted to be in rapid
atrial fibrillation DISEASE and congestive heart failure DISEASE . After a
CTA to rule out PE was done the patient at that time
developed worsening hypoxia DISEASE and was transiently on BiPAP and
went to the Coronary Care Unit. After she was appropriately
rate controlled and diuresed the patient was transferred to
the floor for further management of her atrial fibrillation DISEASE .

PAST MEDICAL HISTORY:
1. Congestive heart failure DISEASE EF of 40 to 50%
2. Moderate to severe mitral regurgitation DISEASE .
3. Hypertension DISEASE .
4. Chronic atrial fibrillation DISEASE .
5. BOOP treated with steroids complicated by steroid
psychosis DISEASE .
6. Glaucoma.
7. OSA DISEASE .
8. History of falls.
9. History of angiopathy DISEASE .
10. Status post cerebrovascular accident times three.
11. Left hip fracture DISEASE .

ALLERGIES: Prednisone causes psychosis DISEASE . Tape and
Bacitracin

MEDICATIONS AS AN OUTPATIENT:
1. Lasix 20.
2. Diltiazem 120 once a day.
3. Lipitor 10 once a day.
4. Coumadin 3 mg alternating with 1.5 mg every other day.
5. Synthroid.
6. Advair.
7. Albuterol.
8. Methazolamide.

PHYSICAL EXAMINATION: The patient was afebrile 97.8. Blood
pressure 140/70. Heart rate 100. Sating 96% on 2 liters
nasal cannula. In general the patient was calm and in no
acute distress. Head and neck examination JVD noted 10 to 11
cm. Heart irregular irregular rapid heart with a systolic
murmur radiating to the apex. Lungs crackles at bases
bilaterally. Abdomen soft and nontender. Extremities show
1Admission Date: [**2133-2-28**] Discharge Date: [**2133-3-6**]

Date of Birth: [**2062-6-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Phenergan

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
transferred to [**Hospital1 18**] for bronchoscopy

Major Surgical or Invasive Procedure:
bronchoscopy

History of Present Illness:
Mrs. [**Known lastname **] is a 70 year old woman with a history of severe COPD DISEASE

NSCLC DISEASE s/p LUL lobectomy [**2126**] s/p XRT vent-dependence has s/p
tracheostomy since [**2130**] status post Y-stent placement
secondary to severe chronic obstructive pulmonary disease DISEASE and
tracheobronchomalacia DISEASE in [**5-6**]. Y stent finally removed on [**7-6**]
due to recurrent migration of Y stent.
Patient has been at rehab where a tracheostomy was noticed to be
malfunctioning for the last days. Per nurse notes on [**2-27**]
patient had a Admission Date: [**2133-3-24**] Discharge Date: [**2133-3-31**]

Date of Birth: [**2062-6-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Phenergan

Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Hemoptysis DISEASE

Major Surgical or Invasive Procedure:
Bronchoscopy

History of Present Illness:
Pt is a 70yo woman with a history of severe COPD NSCLC DISEASE s/p LUL
lobectomy [**2126**] s/p XRT vent-dependence with tracheostomy since
[**2130**] status post Y-stent placement and removal in [**5-6**] h/o
tracheal ulceration recent admission with clogged trach and
blood in trach tube however bronchoscopy with patent airways
and pt discharged on course of Zosyn for possible Pseudomonas
pneumonia DISEASE (possibly sputum cx colonizer) who presented from
rehab today where she was found diaphoretic trach suctioned
resulting in removal of mucous plug followed by persistent blood
in trach tube.

In ED no blood was noted in/around trach. Pt was febrile DISEASE at
101F HR 90s BP 120/50. She was mildly sob and responded to
combivent. She was given Vancomycin and Azithromycin. labs
pertinent for leukocytosis DISEASE and Lactate 1.0.
.
ROS is negative for fever chills cough DISEASE night sweats DISEASE
abdominal pain chest pain hematemesis DISEASE or weight loss DISEASE .

Past Medical History:
1. CHF DISEASE s/p respiratory failure DISEASE s/p trach. ECHO [**5-6**] with EF Admission Date: [**2196-8-20**] Discharge Date: [**2196-8-23**]

Date of Birth: [**2121-4-19**] Sex: M

Service: OMED

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypotension DISEASE

Major Surgical or Invasive Procedure:
Central line placement at Right internal jugular

History of Present Illness:
75 yo male with advanced gastric ca recently started on
chemotherapy presenting and hypotensiona nd episode of
unresponsivenes after diarrhea DISEASE and narcotics Admission Date: [**2126-7-29**] Discharge Date: [**2126-8-2**]


Service: MED

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 242**]
Chief Complaint:
CHF dyspnea DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
88 yo with MMP (see below) who refuses all invasive medical
therapy. Admitted with dyspnea DISEASE increase [**Location (un) **] 5# wt gain.
Patient had CP 2 days prior to admission as well. Eating suasage
at home.
In ED noted to be tachypneic DISEASE with RR in 30s. Appeared in CHF DISEASE
and given 60-60-120 of IV lasix with only 280 UOP. Started on
BiPAP with significant improvement in symptoms. Admission Date: [**2198-5-31**] Discharge Date: [**2198-6-6**]

Date of Birth: [**2125-10-3**] Sex: M

Service: NEUROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
Seizures DISEASE

Major Surgical or Invasive Procedure:
Intubation and ventilation at [**Hospital **] Hospital
Lumbar puncture

History of Present Illness:
cc: Seizures DISEASE versus syncope DISEASE transferred from [**Hospital1 **] at around
3 am [**Hospital1 112**] was at maximal capacity therefore could not accept the
transfer.

72 yo man with an extensive past medical history and of note:
End Stage Renal Disease(started on hemodialysis one month ago)
dialysis days Tue/[**Doctor First Name **]/Sat
Normal pressure hydrocephalus DISEASE & Parkinsonism DISEASE (s/p VP [**Hospital1 5832**]
Hakim programmable shunt placed at the [**Hospital1 756**] in Han [**2198**] on
[**5-25**] setting changed from 9--Admission Date: [**2168-12-29**] Discharge Date:

Date of Birth: [**2129-12-2**] Sex: M

Service: ICU

THIS IS A DICTATION FROM THE HOSPITAL COURSE FROM [**2168-12-29**] THROUGH [**2169-1-14**].

HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old male
with a history of HIV not on HAART no history of
opportunistic infection DISEASE who presented with weeks of
worsening dyspnea DISEASE . The patient refused to see his primary
doctor but the patient's ex-noted that he was becoming
increasingly dyspneic over the month prior to admission. His
mother who had not seen the patient for about a month noted
that he was increasingly short of breath on the phone. On
the day of admission the patient complained of dizziness DISEASE
dyspnea DISEASE with minimal exertion. The patient's ex-roommate
called EMS who brought the patient to the Emergency Room.
Of note the patient was seen at [**Hospital6 1708**]
Emergency Room several weeks prior to this presentation with
shortness of breath and malaise DISEASE . He was sent home without
any therapy.

In the Emergency Department the patient became increasingly
hypoxic on 100% nonrebreather with peripheral oxygen
saturation to be 86%. The patient was intubated and placed
on a sepsis DISEASE protocol. He was aggressively volume
resuscitated and an arterial line was placed after
intubation. The patient became hypotensive DISEASE with systolic
blood pressure in the 70s and was started on a Levophed
drip. The patient was started on broad spectrum antibiotics
and was transferred to the [**Hospital Ward Name 332**] Intensive Care Unit.

PAST MEDICAL HISTORY:
1. HIV. Unknown CD4 and viral load on admission. The
patient was diagnosed about one and a half years ago. He has
never been on HAART therapy secondary to concern about side
effects. He denies any history of opportunistic infection DISEASE .
2. Congenially absent pyoid.
3. Depression.

ALLERGIES: Soap causes a rash DISEASE .

MEDICATIONS ON ADMISSION: Levoxyl 150 mcg po q.d.

FAMILY HISTORY: Unable to be obtained.

SOCIAL HISTORY: Patient lives alone used to have a
roommate. Patient admits to a 25 pack year tobacco history
and quit two weeks prior to admission secondary to shortness DISEASE
of breath. Patient admits to a history of alcohol use and
quit two weeks ago as well. The patient is sexually active
only with men.

PHYSICAL EXAM DISEASE ON ADMISSION: Vital signs: Temperature 102.2.
Blood pressure 80/40. Heart rate 132. Respiratory rate 30s.
Oxygen saturation 64% on room air. In general patient is a
thin anxious appearing male in respiratory distress DISEASE . Head
and neck exam: Bloody mucosa poor dentition foul smelling.
Extraocular movements DISEASE intact. Lungs: Decreased breath
sounds at right base. No crackles. Abdomen soft nontender
nondistended. Good bowel sounds. Extremities: Nails
unkempt. No edema DISEASE . Rectum: Multiple superficial abrasions.
Decreased tone as per Emergency Room. Guaiac negative.

LABORATORY EXAM DISEASE ON ADMISSION: White blood cell count 10.9
hematocrit 33.9 platelet count 396000. Sodium 133
potassium 4.2 chloride 107 bicarbonate 19 BUN 22
creatinine 0.6 glucose 149. Differential on CBC with 74%
neutrophils 8.5% lymphocytes 16% monocytes 1% eosinophils
albumin 1.8 calcium 6.9 phosphorus 3.7 magnesium 1.8 CK
76 troponin less than 0.01 LDH 635 ALT 28 AST 66
alkaline phosphatase 69 total bilirubin 0.9 lipase 149.
Urinalysis: Specific gravity of 1.023 negative nitrate
negative leukocyte esterase negative protein negative
blood lactate 1.7. Admission Date: [**2168-12-29**] Discharge Date: [**2169-1-17**]

Date of Birth: [**2129-12-2**] Sex: M

Service: MEDICAL INTENSIVE CARE UNIT/ACOVE MEDICINE

For detailed hospital course during the patient's
hospitalization in the Medical Intensive Care Unit please
refer to their discharge summary.

CHIEF COMPLAINT: Hypoxic respiratory failure DISEASE and shortness DISEASE
of breath.

HISTORY OF PRESENT ILLNESS: The patient is a 39 year-old
male with a history of HIV diagnosed one year ago with CD4
count currently 25 not on treatment secondary to fear
regarding side effects of medications. The patient also has
a history of hepatitis C. DISEASE He was admitted with weakness DISEASE
progressive worsening dyspnea hypoxia DISEASE and hypotension DISEASE and
fever DISEASE . The patient was brought to the Emergency Room by EMS.
In the Emergency Room his temperature was 102.2 pulse 130
oxygenation 64% on room air and 86% on a nonrebreather.
Blood pressure was 67/36 and lactate was 4.0. The patient
received 7 liters of intravenous fluids of normal saline
intubated sedated right IJ and A line were placed. The
patient was started on Ceftriaxone Flagyl Vancomycin
Levophed GTT CVP increased to 12 with MBO2 75%. Chest
x-ray with diffuse bilateral infiltrates concerning for PCP
sepsis DISEASE protocol initiated. The patient was intubated for a
total of two times for hypoxic respiratory failure DISEASE . His
bronch was positive times two for PCP and the patient was
started on Bactrim steroids. The patient also developed
perirectal HSV type 2 lesions and started on Acyclovir. The
patient had one out of four bottles of coag negative staph
species felt to be contaminate and this was Admission Date: [**2168-12-29**] Discharge Date: [**2169-1-17**]

Date of Birth: [**2129-12-2**] Sex: M

Service: A-COVE

The patient was initially admitted to the Medical Intensive
Care Unit and secondarily transferred to the A-Cove Medicine
Service under the care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. For detailed
hospital course during patient's hospitalization in the
Intensive Care Unit please refer to their discharge summary.

CHIEF COMPLAINT: Hypoxic respiratory failure DISEASE and shortness DISEASE
of breath.

HISTORY OF PRESENT ILLNESS: This is a 39-year-old male with
a history of HIV diagnosed one year ago with CD-4 count
currently 25 not on treatment secondary to fear regarding
side effects of medication. Patient also has a history of
hepatitis B. DISEASE He was admitted with weakness DISEASE progressive
worsening dyspnea hypoxia DISEASE and hypotension DISEASE and fever DISEASE . The
patient was brought to the Emergency Room by EMS and in the
Emergency Room his temperature was 102.2 pulse 130.
Oxygenation was 64% on room air and 86% on a non-rebreather.
Blood pressure was 67/36 and lactate was 4.0. The patient
received seven liters of intravenous fluid normal saline
was intubated sedated. Right internal jugular A-line was
placed. The patient was started on ceftriaxone Flagyl
vancomycin Levophed GTT CVP increased to 12 with MBO2 75%.
Chest x-ray with diffuse bilateral infiltrates concerning for
PCP. [**Name10 (NameIs) **] protocol initiated. Patient intubated for a
total of two times for hypoxic respiratory failure DISEASE . His
bronch Admission Date: [**2102-7-12**] Discharge Date: [**2102-7-19**]

Date of Birth: [**2024-1-14**] Sex: M

Service: ORTHOPAEDICS

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 64**]
Chief Complaint:
left hip pain DISEASE

Major Surgical or Invasive Procedure:
left total hip replacement - revision


History of Present Illness:
Mr. [**Known lastname 5849**] was working in his
cellar on [**2101-10-1**] when he tripped and fell on a step
and sustained a left subcapital hip fracture DISEASE . As you know this
was treated with an uncemented Osteonics Omnifit
hemiarthroplasty
on [**2101-10-2**]. This was performed through an
anterolateral approach. His postoperative course was
uneventful.
Over the ensuing months he did receive treatment from an
orthopedic surgeon in [**State 108**] whereby he was given
viscosupplementation injections of the left knee. He did not
have any improvement of his knee pain DISEASE at that time.
Subsequently in [**2102-3-13**] he was admitted with pneumonia DISEASE . At
that time his hip was painful and an x-ray revealed subluxation DISEASE
of the hemiarthroplasty. Aspiration was positive for infection DISEASE .

The aspiration white cell count on [**2102-4-11**] was 35500
with
97% polys. The patient was then taken to the operating room by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who performed a resection of the
hemiarthroplasty irrigation and debridement and spacer with
antibiotic cement. Tissue culture on [**2102-4-12**] revealed
coagulase negative Staphylococcus DISEASE as well as propionibacterium
acnes. The patient was then subsequently treated with
intravenous antibiotics and the spectrum was widened to include
vancomycin ceftriaxone and azithromycin. He was discharged on
an antibiotic regimen of vancomycin and ceftriaxone and
demonstrated improvement in his fevers DISEASE and pain DISEASE . He completed
five weeks of intravenous vancomycin. He developed Clostridium DISEASE
difficile infection DISEASE on [**2102-5-16**] which was treated with
Flagyl.
For this reason IV antibiotics were discontinued at five weeks
rather than six weeks. Mr. [**Known lastname 5849**] now presents for assessment
for reimplantation of the hip.


Past Medical History:
CAD s/p DES to RCA in [**11-20**]
Prostate cancer DISEASE s/p radical prostectomy [**2093**]
Hypertension DISEASE
Hypothyroidism DISEASE dx early [**2082**]
Glaucoma DISEASE
s/p bilateral ankle surgery
carpal tunnel s/p surgical release [**2100**]
s/p L hernia DISEASE repair [**2086**]

Social History:
Pt lives with wife in [**Name (NI) 1468**] recently from nursing home. He
denies current tobacco use or illicit drug use. Admits to
occasional glass of wine. Used to own a sub shot.


Family History:
nc

Physical Exam:
well-appearing well nourished 78 year old male
alert and oriented
no acute distress
LLE:
-dressing-c/d/i
-incision-c/d/i Admission Date: [**2200-12-28**] Discharge Date: [**2200-12-31**]

Date of Birth: [**2129-6-25**] Sex: M

Service: CCU

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 5850**] is a 71-year-old
male with an extensive cardiac history. His last cardiac
catheterization was [**7-25**] during which he had a stent to his
D1 and presented with unstable angina DISEASE . Patient describes
stable angina DISEASE as substernal chest pain DISEASE with walking Admission Date: [**2121-3-18**] Discharge Date: [**2121-3-26**]

Date of Birth: [**2086-12-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Codeine / Nsaids / Levaquin

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Palpitations

Major Surgical or Invasive Procedure:
Pulmonary vein isolation / ablation


History of Present Illness:
Ms. [**Known lastname **] is a 34 yo female with hypertrophic cardiomyopathy DISEASE
obesity anxiety DISEASE multifocal atrial tachycardia DISEASE atrial
fibrillation left atrial tachycardia DISEASE and AVNRT DISEASE . She was
admitted after pulmonary vein isolation complicated by atrial
tachycardia DISEASE requiring cardioversion and SOB from pulm edema DISEASE
requiring post-procedure re-intubation.

The patient was admitted for elective pulmonary vein isolation.
Both groin veins were accessed for the procedure. At the end of
the procedure she developed atrial tachycardia DISEASE with 2:1 block
at a rate of approximately 100. This atrial tach was not ablated
though she was cardioverted back to NSR. She was successfully
extubated after cardioversion. She had received an estimated
4.5L of fluid during the procedure. She developed shortness of
breath after extubation. Exam and CXR were concerning for
pulmonary edema DISEASE . She responded well to 40mg IV lasix x2 with an
estimated 3L urine output. Nonetheless the patient's shortness
of breath worsened saturating 92% on NRB DISEASE and speaking in short
sentences. She required re-intubation and received propofol and
vecuronium during intubation.

She has been hospitalized several times over the past 1-2 months
with symptoms of palpitations DISEASE and dyspnea DISEASE associated with atrial
arrhythmias DISEASE .

Past Medical History:
Hypertrophic cardiomyopathy DISEASE on transplant list
Intermittent atrial fibrillation DISEASE
s/p cardiac arrest DISEASE at age of 16yo
s/p MVA
Chronic back pain DISEASE
Asthma
COPD DISEASE
Bipolar DISEASE
Anxiety DISEASE
s/p appendectomy
multiple cardiac caths
s/p cardioversion
.
Cardiac Risk Factors: - Diabetes - Dyslipidemia - Hypertension DISEASE
.
Cardiac History:
The patient initially presented with syncope DISEASE at age of l2. At
l3 the patient was seen at [**Hospital3 1810**] for history of
syncope chest pain DISEASE and progressive exercise intolerance DISEASE . She
was found to have hypertrophic cardiomyopathy DISEASE . She was
subsequently cathed. Left
ventricular end diastolic pressure was found to be 20. She was
then started on chronic Verapamil therapy. At age l6 she
experienced cardiac arrest DISEASE secondary to complex tachycardia DISEASE . She
was successfully resuscitated. Repeat catheterization showed
left ventricular end diastolic pressure of 36-40 without outflow
tract obstruction DISEASE . EP showed inducible atrial flutter DISEASE with a
rapid ventricular blood pressure. She was felt to have a rapid
antegrade
conduction and possible pre-excitation DISEASE . She was started on
Norpace. Since then the patient has been stable on Verapamil
and Norpace with occasional palpitations chest pain DISEASE and light
headedness DISEASE .
.

Social History:
Currently on disability. 40 pack-year smoker (2ppd x20 years)
quit since recent bronchitis DISEASE . No EtOH. Regular marijuana use.
Family history remarkable for hypertrophic cardiomyopathy DISEASE and
congenital aortic stenosis DISEASE s/p cardiac surgery during infancy.
No family history of sudden cardiac death DISEASE or premature CAD DISEASE .

Family History:
There is no family history of premature coronary artery disease DISEASE
or sudden death DISEASE . Mom has DM HTN. Her son has aortic stenosis DISEASE
and hypertrophic cardiomyopathy DISEASE .

Physical Exam:
ADMISSION PHYSICAL EXAM DISEASE :
VS: 98.2-99.2 60-80 100-120/40-60 SIMV RR 10 Vt 650 FiO2 60 PEEP
8 99%
Gen: Obese. Intubated and sedated.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Coarse breath sounds bilaterally in part due to upper
airway congestion DISEASE .
Abd: Soft nontender. No organomegaly DISEASE or masses.
Ext: No edema DISEASE . Bilateral palpable 1Admission Date: [**2121-4-5**] Discharge Date: [**2121-5-9**]

Date of Birth: [**2086-12-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Codeine / Nsaids / Levaquin

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
transfer s/p pericardial window

Major Surgical or Invasive Procedure:
none

History of Present Illness:
In brief this is a 34 yoF with hypertrophic cardiomyopathy DISEASE
multiple atrial arrhythmias DISEASE including atrial tachycardia DISEASE atrial
fibrillation left atrial tachycardia DISEASE and AVNRT DISEASE s/p recent
pulmonary vein isolation procedure [**2121-3-18**] c/b peristent atrial
tachycardia respiratory failure DISEASE and pneumonia DISEASE who was
readmitted to [**Hospital1 18**] on [**2121-4-5**] with chest pain DISEASE and shortness of
breath. She initially presented to an OSH w/ intermittent [**11-21**]
chest pain DISEASE radiating to the arms associated with SOB. CT chest
was negative for PE or dissection. She was found to have a
pericardial effusion DISEASE with RV compression DISEASE as well as a
pericardial clot on TTE. She was sent to the OR for pericardial
window on [**2121-4-5**] which showed Admission Date: [**2200-4-7**] Discharge Date: [**2200-5-30**]

Date of Birth: [**2166-12-24**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Codeine / Ceftriaxone

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
MS changes (tx'd from OSH)

Major Surgical or Invasive Procedure:
[**2200-4-11**]- R Hip washout secondary to infected hardward
[**2200-4-17**]- R Hip Hardware removed
[**2200-4-24**]- R Hip washed out and wound closed
[**2200-5-8**]- Removal of infected hematoma DISEASE in R hip
[**2200-5-22**]- R hip Washout


History of Present Illness:
33 y/o male with PMH significant for AVR NIDDM DISEASE h/o
polysubstance abuse DISEASE initially admitted to OSH on [**2200-3-25**] for s/p
tonic-clonic seizure DISEASE resulting in a fall and broke right hip
requiring R hip ORIF on [**2200-3-31**]. It was felt that seizure DISEASE was
secondary to benzo withdrawal as pt was taking 5 mg of Xanax tid
at home. He was then to d/c'd to transitional care rehab on
[**2200-4-2**] to be later admitted on [**2200-4-3**] for AMS/seizures.
In the ED at OSH loaded with 1 gm dilantin 2 mg ativan and 2
mg dilaudid and admitted. Per records pt not on benzos while at
rehab. EEG from [**4-4**] and [**4-5**] showed no localizing seizure DISEASE
activity.
On [**2200-4-6**] pt became lethargic tachypneic w/rr in 40's and
hypoxic. He was also reportedly febrile (unknown temp). He
received one dose of CTX which resulted in a skin rash DISEASE . He was
then transferred to the ICU with concerns for NMS DISEASE vs. sertonin
syndrome vs. benzo-withdrawal vs. infection/sepsis.
ICU course at OSH notable for start of ativan gtt and
psychotropic meds including risperdal seroquel wellbutrin
and xanaflex. WBC count at 11 Cr 4.4 LFTs wnl at that time.
Dilantin level 7.7 at that time. Daily head CT's from [**4-4**] to
[**4-6**] were all normal. During this time pt became hyperkalemic DISEASE
to 5.4 and acidotic with bicarb of 18. ABG on [**2200-4-6**] was
7.2/24/72/16. Pt was then started on a bicarb gtt. Lactate was
1.2 serum and urine tox unremarkable except for benzos. Pt was
ROMI with enzymes during his course. TTE today showed preserved
EF moderate AS/AI moderate MR DISEASE elevated RV pressures of 91.


Past Medical History:
1)AVR in [**2190**] for Enterococcus faecalis endocarditis DISEASE
2)Cellulitis x 6
3) DM II diagnose in [**4-21**] treated with glipizide
4)Polysubstance use (cocaine opiates benzos anabolic
steroids)
5) H/O pancreatitis DISEASE in [**2194**]
6) Cluster HA's
7) Neck and back pain DISEASE - has been to musculoskeletal specialist
as well as PT
8) Anxiety DISEASE
9) ADHD/ADD
10) Left pectoral and biceps tear s/p surgery


Social History:
Recently divorced currently lives with girlfriend. Moved to
[**Location (un) 86**] 6 months ago from [**State 5864**]. h/o IVDU. Unemployed.

Family History:
DM
Hyperlipidemia DISEASE
Fibromyalgia (sister)
Multiple staph infections DISEASE
DVT DISEASE


Physical Exam:
VS - 99.6 110/59 112 25-30 95%/3LNC
General - Somnolent awakens with loud voice and tactile
stimulation
HEENT - NC/AT PERRL EOMI. MM dry
Neck - supple
Chest - CTA-B no w/r/r
CV - RRR s1 s2 normal Admission Date: [**2175-9-27**] Discharge Date: [**2175-9-28**]

Date of Birth: [**2101-11-11**] Sex: M

Service: SURGERY

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 158**]
Chief Complaint:
rectal bleeding DISEASE following prostate biopsy

Major Surgical or Invasive Procedure:
1. prostate biopsy
2. exam under anesthesia
3. ligation of post-prostate biopsy bleeding DISEASE


History of Present Illness:
The patient is a 73-year-old man who underwent a prostate biopsy
in [**Hospital 159**] clinic complicated by immediate significant bright
red blood bleeding DISEASE . Attempts were made to stop the bleeding DISEASE with
a dilating Foley balloon and Surgicel packing without success.
He was admitted for surgical management of bleeding DISEASE .


Past Medical History:
hyperlipidemia coronary artery disease prostate cancer gout DISEASE

Social History:
Retired as a waiter in a Chinese restaurant. Patient is an
accomplished poet who has published works in Chinese. Daughter
is nurse. Tobacco none ETOH: None Drugs: None


Family History:
non-contributory

Physical Exam:
VS T 98.5 HR 68 BP 91/52 RR 18 SpO2 98%RAAdmission Date: [**2195-10-6**] Discharge Date: [**2195-10-20**]


Service: NMED

Allergies DISEASE :
Naproxen / Diltiazem / Propranolol

Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Dizziness DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Patient is an 85 year old woman with past medical history of
hypertension DISEASE hypercholesterolinemia and vertebral aneurysm DISEASE who
presents with dizziness DISEASE . She awoke on the morning of admission
with sense of dizziness DISEASE and dysequilibrium DISEASE like things were
moving around her. The sensation was worsened with head
movements and present in all positions. She denied any nausea DISEASE
diplopia DISEASE or neck pain DISEASE . When she walked felt unsteady and had
to hold onto things to steady herself. She then had developed a
pain DISEASE which she is unable to characterize further all over her
head that build up to [**9-1**] but is now [**5-2**]. She also complained
of photophobia DISEASE but denied any visual speaking or swallowing
difficulties. Of note she did have a cough DISEASE but no fever DISEASE in
past week. She denied any recent trauma DISEASE or neck manipulations.

Her neighbor came over and then called 911Admission Date: [**2200-3-24**] Discharge Date: [**2200-4-5**]

Date of Birth: [**2137-1-6**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Penicillins / Tetracycline / Codeine

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea/Chest pain DISEASE

Major Surgical or Invasive Procedure:
[**2200-3-24**] - Re-do sternotomy AVR (21mm St. [**Male First Name (un) 923**] mechanical)


History of Present Illness:
This 62 year old patient with previous coronary artery bypass
grafting in [**2180**] presented at this time with symptoms of chest
pain DISEASE and dyspnea DISEASE on exertion. He was investigated and was found
to have residual disease in the obtuse marginal graft and also
severe aortic stenosis DISEASE and mild to moderate mitral
regurgitation. He had no viable leg veins to be used as
conduits and hence preoperatively the obtuse marginal vein
graft was stented successfully and he was electively admitted
for aortic valve replacement with or without mitral valve repair
or replacement.

Past Medical History:
Coronary artery disease DISEASE
s/p CABGx4 [**6-/2181**]
CRI with acute creatinine rise post cardiac catheterization
MI [**2193**]
PVD DISEASE
AF
DVT DISEASE
Diabetes DISEASE
HTN DISEASE
Neuropathy/Retinopathy DISEASE
Iron deficiency anemia DISEASE
Depression/Anxiety DISEASE
s/p Subdural hematoma DISEASE with evacuation
Multiple PCI's
Atrial Flutter DISEASE ablation [**2190**]
Multiple toe amputations
Green Field Filter placement
s/p Right lower extremity bypass
Left saphenous vein harvest
Aortic stenosis DISEASE

Social History:
Lives with wife in [**Name (NI) 5871**] MA. Prior alcohol and drug abuse DISEASE
(pills/cocaine). He is disabled. Smoked [**12-2**] ppd stopping in
[**2195**].


Family History:
2 uncles died of [**Name (NI) 5290**] at age 57 and 60.

Physical Exam:
52 SB BP (R) 132/70 (L) 140/74 98% RA DISEASE Weight 230 73Admission Date: [**2201-1-29**] Discharge Date: [**2201-2-19**]

Date of Birth: [**2137-1-6**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Penicillins / Tetracycline / Codeine

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
gastro-intestinal bleed DISEASE

Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy x3
capsule endoscopy x2
PICC line placement


History of Present Illness:
The patient is a 64 M with CAD s/p 4V-CABG [**2180**] AVR [**2200-3-24**] [**Male First Name (un) 923**] mechanical valve HTN DISEASE AFIB DM2 DISEASE transferred from
[**Hospital 5871**] Hospital to [**Hospital1 18**] ICU for workup of acute GIB DISEASE . Admitted
to [**Location (un) 5871**] on [**1-11**] considering replacing his mechanical with
porcine valve but there he had CP and dizziness DISEASE per GI consult
note there but was found to have INR 5 and Hct 18. Over 2
weeks he received 14 U RBC Hct up to 30s but then drifted
down. Did capsule limited by food but possibly melena DISEASE EGD
negative bleeding DISEASE scan negative found blood trickling down
from terminal ileum. Patient did not notice any blood but blind
in R eye and mostly blind in L eye. Patient was transferred to
[**Hospital1 18**] for further evaluation and potential replacement of
metallic aortic valves with porcine valve that would not require
anti-coagulation.

Past Medical History:
Coronary artery disease DISEASE
s/p CABGx4 [**6-/2181**] last cath [**1-/2200**]: Three vessel coronary artery
disease. Successful stenting of the SVG-OM with drug-eluting
stent.
CRI with acute creatinine rise post cardiac catheterization
MI [**2193**]
PVD DISEASE
AF
DVT DISEASE
Diabetes DISEASE
HTN DISEASE
Neuropathy/Retinopathy DISEASE
Iron deficiency anemia DISEASE
Depression/Anxiety DISEASE
s/p Subdural hematoma DISEASE with evacuation
Multiple PCI's
Atrial Flutter DISEASE ablation [**2190**]
Multiple toe amputations
Green Field Filter placement
s/p Right lower extremity bypass
Left saphenous vein harvest
Aortic stenosis DISEASE

Social History:
Lives with wife in [**Name (NI) 5871**] MA. Prior alcohol and drug abuse DISEASE
(pills/cocaine). He is disabled. Smoked [**12-2**] ppd stopping in
[**2195**]. Does not drink or use drugs at this time.


Family History:
2 uncles died of [**Name (NI) 5290**] at age 57 and 60.

Physical Exam:
VS: 97.0 / 100/60 / 81 / 20 / 97% RA DISEASE
Gen: sleeping but arousable NAD w/o complaint DISEASE
HEENT: R eye completely blind L eye partially blind. L PERRL L
EOMI oropharynx clear w/o erythema mouth DISEASE with poor dentition
Neck: supple no LAD JVD 6
Chest: CTA B well-healed sternotomy scar
CV: Irregularly irregular S1 S2 with with mechanical click. No
murmurs
Abd: Soft obese ND NT Admission Date: [**2112-6-7**] Discharge Date: [**2112-6-22**]

Date of Birth: [**2038-6-4**] Sex: M

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p fall

Major Surgical or Invasive Procedure:
[**6-8**]: attempted laminectomy (aborted for bleeding DISEASE )
[**6-10**]: C4-T3 laminectomy C4-T1 fusion
[**6-14**]: C4-C7 anterior fusion

History of Present Illness:
74M on coumadin for a fib s/p unwitnessed DISEASE fall down several
flights of stairs Admission Date: [**2128-6-16**] Discharge Date: [**2128-6-20**]

Date of Birth: [**2059-3-29**] Sex: F

Service: PLASTIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Asymmetric breast tissue as a result of mastectomy secondary to
breast cancer DISEASE

Major Surgical or Invasive Procedure:
1. Left delayed deep inferior epigastric DISEASE perforator flap ([**Last Name (un) 5884**]
flap).
2. Harvest of deep inferior epigastric artery DISEASE and vein pedicle
at pelvis.
3. Autologous fat grafting vascular pedicle.


History of Present Illness:
The patient is a 68-year-old woman with a history of left breast
cancer DISEASE . She underwent a mastectomy followed by chemotherapy and
radiation therapy. She
finished her radiotherapy in [**2126-8-29**]. She presented to Dr
[**First Name (STitle) **] interested
in breast reconstruction and was admitted to the hospital for
[**Last Name (un) 5884**] (deep inferior epigastric DISEASE perforator) flap reconstruction
to her left chest wall.


Past Medical History:
1. Left breast cancer DISEASE status post treatment with Taxol and
Herceptin. Initially underwent left partial mastectomy but
returned for left modified radical mastectomy in [**5-1**].
2. Hypertension DISEASE
3. Status post excision of ganglion cyst in hand




Social History:
The pt is married and lives with her husband. Homemaker.
Emigrated from [**Country 2045**] Admission Date: [**2129-9-21**] Discharge Date: [**2129-9-21**]

Date of Birth: [**2059-3-29**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypothermia hypotension lactic acidosis DISEASE

Major Surgical or Invasive Procedure:
Intubation femoral CVL femoral arterial line

History of Present Illness:
Patient is a 70 year old female with past medical history of
coronary artery disease hypertension CVA DISEASE and breast cancer DISEASE
who was recently discharged from [**Hospital1 18**] on [**9-16**]. Per report from
the emergency room physicians her daughter went to visit the
patient today and noted the patient was cold breathing fast
and felt unwell. EMS was called and upon arrival the patient
was noted to be tachypneic DISEASE with a respiratory rate to the 40's
cold sweaty and hypotensive DISEASE with a blood pressure of 70/palp.
EMS was unable to obtain a temperature or start an IV in the
field.
.
Upon arrival to [**Hospital1 18**] ED patient was noted to be tachypneic DISEASE
and was placed on a non-rebreather. The ED staff had a difficult
time obtaining a blood pressure (erratic and felt to be
erroneous readings of 190's obtained) and ultimately a mannual
cuff provided [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] of systolic of 85. Again it was
difficult to place a peripheral IV so a left EJ was placed.
Ultimately a femoral central line was placed as with her
persistent tachypnea DISEASE a neck line was felt unsafe. Her breathing
improved to a rate in the 20's and she was placed on nasal
cannula oxygen with a saturation in the 90's. She received three
liters of intravenous fluid. A chest x-ray was felt to possibly
be consistent with pneumonia DISEASE so she was given levofloxacin
zosyn and vancomycin to cover for possible aspiration and
hospital-acquired DISEASE pathogens given her recent stay. Of note she
remained hypothermic and a rectal probe was unable to read a
temperature. With warm blankets her temperature improved to 92
rectally at time of transfer. Her labs were notable for a
lactate of 9.5 troponin at her baseline (0.06) and a bump in
her creatinine to 2.3 (previously 1.4).
.
Upon arrival to the floor patient denies any discomfort or
pain DISEASE but states she feels cold. She cannot provide any details
regarding the events leading to hospitalization.

Past Medical History:
Dyslipidemia DISEASE
Hypertension DISEASE
Recent Inferior STEMI ([**6-/2129**])
Left breast cancer DISEASE s/p modified radical mastectomy [**2125**]Admission Date: [**2129-8-8**] Discharge Date: [**2129-8-9**]

Date of Birth: [**2075-2-14**] Sex: M

Service: MEDICINE

Allergies DISEASE :
IodineAdmission Date: [**2188-10-28**] Discharge Date: [**2188-11-4**]

Date of Birth: [**2120-4-18**] Sex: M

Service: CSU


HISTORY OF PRESENT ILLNESS: This is a 68-year-old male
patient with a long history of coronary artery disease DISEASE
status post multiple percutaneous interventions in past 35
years with his last intervention in [**2187-4-29**] who presented
to an outside hospital on the morning of [**2188-10-28**] with
complaints of chest pain DISEASE at rest no troponin leak at that
outside hospital who was transferred to the [**Hospital1 18**] for cath
showing severe 3VD with a left main stenosis of 60 percent
LAD 50-60 percent left circ 80 percent RCA 90 percent
distal involving the PDA who was referred at this time for
coronary artery bypass grafting.

PAST MEDICAL HISTORY: Coronary artery disease DISEASE status post 6-
7 stents in the past.

Hyperlipidemia DISEASE .

Gout DISEASE .

Gastroesophageal reflux disease DISEASE .

Depression DISEASE .

PAST SURGICAL HISTORY: Right carotid endarterectomy
approximately 5 years ago.

Appendectomy as a child.

ALLERGIES: No known drug allergies DISEASE .

MEDS PRIOR TO ADMISSION:
1. Lescol 80 mg once daily.
2. Folate 1 mg once daily.
3. Prevacid 30 mg once daily.
4. Colchicine 0.6 mg [**Hospital1 **].
5. Zetia 10 mg once daily.
6. Wellbutrin SR 150 mg [**Hospital1 **].
7. Cardizem CD 240 mg once daily.
8. Colace 100 mg [**Hospital1 **].
9. Allopurinol 100 mg once daily.
10.Provigil 100 mg once daily.
11.Imdur 30 mg q am and 15 mg q pm.
12.Plavix 75 mg once daily.
13.Ecotrin 325 mg once daily.
14.Diovan/HCTZ 160/12.5 once daily.
15.Vitamin B6 50 mg once daily.

PHYSICAL EXAM ON PRESENTATION: Height 5 feet 8 inches tall
weight 250 pounds. Vital signs: Blood pressure 118/66
heart rate 54 and sinus rhythm temp 97.1. General: Lying
flat in bed in no acute distress. Neuro: Alert and oriented
x 3 appropriate. Respiratory: Clear to auscultation.
Cardiovascular: Regular rate and rhythm S1 S2 II/VI
systolic ejection murmur loudest at the apex. GI: Soft
obese nontender nondistended with positive bowel sounds.
Extremities: Warm and well-perfused no edema DISEASE no
varicosities with good distal pulses.

LABS ON ADMISSION: WBC 5.7 hematocrit 44.3 platelets 156
PT 13.0 PTT 26.5 INR 1.1 sodium 137 potassium 3.7
chloride 100 bicarb 28 BUN 16 creatinine 0.9 glucose 153
ALT 42 AST 27 alk phos 70 total bili 0.5 albumin 4.0.

SUMMARY OF HOSPITAL COURSE: As above the patient was
admitted on [**2188-10-28**] and proceeded to the Cardiac Cath Lab
showing severe 3VD and was referred for coronary artery
bypass grafting. He underwent a preop evaluation and was
cleared for CABG and proceeded to the operating room on
[**2188-10-30**] and underwent coronary artery bypass grafting x 4
with Dr. [**Last Name (STitle) **] with a LIMA to the LAD saphenous vein graft
to the OM left PDA and right PDA. He was transferred to the
Cardiac Surgery Recovery Room AV-paced DISEASE with a rate of 88
mean arterial pressure of 76 and CVP of 14. He was
sustained on Neo-Synephrine and propofol drips. His
underlying rhythm initially was a sinus bradycardia DISEASE with a
rate in the 30's.

Postoperative day 1 was significant for successful extubation
and return of his heart rate to 62 in a normal sinus rhythm.
On postoperative day 4 the rest of his intravenous
medications were discontinued and his Foley catheter was
also discontinued and he was transferred to the inpatient
floor for continued care.

Postoperative day 3 and 4 were also uneventful with heart
rate continuing in sinus rhythm not requiring any cardiac
pacing. His pacing wires were thus DC'd and his usual meds
were resumed. Mr. [**Known lastname 3075**] was followed by the physical
therapy team throughout his recovery and on [**2188-11-3**] met
all goals of therapy and was DC'd from a physical therapy
standpoint.

On postoperative day 5 [**2188-11-4**] Mr. [**Known lastname 3075**] was found to
be medically ready for home and was discharged home with
visiting nurses to follow.

CONDITION ON DISCHARGE: Vital signs: Temp 97 pulse 62 in
sinus rhythm BP 130/Admission Date: [**2196-4-27**] Discharge Date: [**2196-5-3**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Atenolol

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe mass


Major Surgical or Invasive Procedure:
[**2196-4-27**]: Right thoracotomyAdmission Date: [**2167-4-9**] Discharge Date: [**2167-5-3**]

Date of Birth: [**2086-6-6**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 598**]
Chief Complaint:
trauma DISEASE transfer from OSH s/p unwitness fall right rib
fractures DISEASE right pneumothorax DISEASE spinal compression fractures DISEASE

Major Surgical or Invasive Procedure:
placement of right chest tubes done at bedside (x3)
pleurodesis right lung done at bedside


History of Present Illness:
Patient is an 80 year old patient who experienced a witnessed
fall onto concrete. She had no recollections of the events. She
craweled into the house and was found by her son. At that time
she was in respiratory distress DISEASE and complained of right chest
pain DISEASE . She was brought to the [**Hospital3 628**] and was
subsequently transferred here. She was found to have a
pneumothorax DISEASE on the right and chest tubes were placed at OSH.
Patient had small abrasions DISEASE on the right forearm and right knee.
She was hemodynamically stable on arrival.
Patient was also found to have compression fractures DISEASE of L4 L5
T6 T7 T9 T12.

Patient has no prior history of trauma DISEASE .

Past Medical History:
PMH:
COPD DISEASE on O2 at home ranges from 2-2.5 LNC
hypertension DISEASE
hyperlipedemia DISEASE
Dementia DISEASE
Depression DISEASE
Osteoporosis DISEASE

PSH DISEASE :
surgical excision of [**Last Name (un) 5902**] neuroma

Social History:
- patient lives with son
- is retired
- smokes 1 pack of cigarettes a day
- denies etoh and drug use

Family History:
non-contributory

Physical Exam:
PE:
VS: Tm 98.8 HR 78 BP 132/76 RR 20 O2 sat 98% on 2L/min NC
gen: WA/WD NAD
CV: RRR no m/r/g
pulm: CTA b/l
abdomen: Admission Date: [**2175-9-29**] Discharge Date: [**2175-10-4**]

Date of Birth: [**2101-11-11**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina DISEASE and STEMI

Major Surgical or Invasive Procedure:
[**2175-9-29**] cardiac cath
[**2175-9-29**] CABG X5 (LIMA to LAD SVG to DIAG SVG to OM1Admission Date: [**2116-6-1**] Discharge Date: [**2116-6-10**]

Date of Birth: [**2037-5-2**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Bright red blood loss DISEASE per rectum

Major Surgical or Invasive Procedure:
Colonoscopy


History of Present Illness:
Ms. [**Known lastname 5903**] is a 79 yo female with h/o CAD PVD DM2 CKD DISEASE and
diverticulosis DISEASE who presented on [**2116-6-1**] with BRBPR on multiple
BMs starting the day of arrival. She had no cramping pain DISEASE
nausea DISEASE or other symptoms at the time. VS were stable in the
ED and Hct was noted to be dropping from 35 recently to 30 and
then to 27 with continued bloody BMs.

ROS was negative for fevers chills DISEASE unintentional weight
changes orthopnea chest pain dyspnea abdominal pain DISEASE easing
bruising dysuria DISEASE and rashes DISEASE .

Past Medical History:
- CAD s/p CABG [**2107**]
- PVD
- CKD DISEASE stage III
- HTN DISEASE
- DM2 DISEASE complicated by retinopathy nephropathy DISEASE
- diverticulosisAdmission Date: [**2117-3-30**] Discharge Date: [**2117-4-3**]

Date of Birth: [**2037-5-2**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 5510**]
Chief Complaint:
Lower GIB DISEASE

Major Surgical or Invasive Procedure:
4 units of packed red blood cells

History of Present Illness:
79 year old female with a past history of hypertension DISEASE type 2
diabetes CAD DISEASE s/p CABG x 4 and history of lower gastrointestinal
bleeding DISEASE of unclear source who presents to the emergency room
with 4 days of Admission Date: [**2166-10-14**] Discharge Date: [**2166-10-20**]

Date of Birth: [**2137-3-5**] Sex: F

Service: OBSTETRICS/GYNECOLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Doctor First Name 5911**]
Chief Complaint:
Menometrorrhagia pelvic pain DISEASE .

Major Surgical or Invasive Procedure:
1. Abdominal Supracervical hysterectomy
2. Exploratory laparotomy and hematoma DISEASE evacuation
3. Cystoscopy & retrograde ureterogram


History of Present Illness:
The patient is a 29-year-old G5 P1-1-3-2 thin African-American
female with a large symptomatic fibroid DISEASE uterus complaining of
prolonged menometrorrhagia DISEASE as well as severe pelvic pain DISEASE who
presented with severe anemia DISEASE with a hematocrit of 25.

The patient was being evaluated by her PCP for suspected
underlying thalassemia DISEASE . Iron studies revealed severe
iron-deficiency anemia DISEASE however the patient was not compliant
with p.o. iron. Given the source of anemia DISEASE was likely due to her
fibroid uterus the patient was transfused 2 units of packed red
blood cells 1 day preoperatively as well as 125 mg of Ferrlecit
IV to try to
improve her iron stores and blood supply. The patient was
offered to delay the surgery to improve her iron stores with
p.o. iron however the patient had been noncompliant and
declined this option. The risks of infection DISEASE with blood
transfusion as well as the side effects of blood transfusion
were discussed with the patient at length. The patient was
counseled extensively and she opted for the preop transfusion
and IV iron and to proceed with the surgery. Even after the
patient was transfused the 2units of packed red blood cells her
post-transfusion heamtocrit was only 27 since she continued to
bleed DISEASE heavily from her uterine fibroids DISEASE since the last HCT of
25.

Past Medical History:
PMH: She states that she is otherwise healthy with
the exception of this left lower extremity swelling episode
which was not painful unclear etiology. She is currently not
being evaluated as she was not compliant with followup with her
PCP after the emergency room visit.

PAST SURGICAL HISTORY:
1. D&C x2 for elective termination of pregnancies.
2. Her IUFD DISEASE at 6 months was successfully delivered vaginally
with an induction of labor DISEASE .


Social History:
Admits to smoking 3 cigarettes per day for the last 2 years.
Also admits to drinking occasionally 3 drinks per week on
Fridays. Denies any recreational drug use or IV drug use. She
is currently employed as an administrative assistant at [**Hospital1 **] at
the Radiation Oncology Department. She is single not
currently dating lives with her mother. Denies a history of
sexual abuse DISEASE and domestic violence.

Family History:
Mother maternal aunt and maternal niece with history of breast cancer DISEASE . She has a sister who is alive and well without breast cancer DISEASE . Denies DISEASE a family history of ovarian uterine DISEASE cervical
or vaginal cancer DISEASE or colon cancer DISEASE or any
other cancers DISEASE in the family. Also denies family history of
diabetes heart disease DISEASE or hypercholesterolemia DISEASE . Paternal
grandmother and sister both suffer from hypertension DISEASE . Denies
any other significant family medical history.


Physical Exam:
Vitals T:98.6F HR:60 RR:16
GEN: NAD
CVS: RRR
Resp: CTAB
ABD: (post-op) soft non-tender Admission Date: [**2135-4-19**] Discharge Date:

Date of Birth: [**2064-10-26**] Sex: F

Service: CARDIOTHORACIC SURGERY

HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
female with known history of coronary artery disease DISEASE referred
for outpatient cardiac catheterization secondary to a
positive stress test. The patient had a PTCA stent to the
right coronary artery on [**2131-6-2**]. Cardiac catheterization
in [**2132-4-2**] showed 50% right coronary artery with a patent
stent 50% mid left anterior descending 75% circumflex 95%
OM and 70% diagonal.

The patient had been doing well and denied any chest pain DISEASE .
She did report having dyspnea DISEASE on exertion over the past 1-2
months and had been getting shortness of breath DISEASE from walking
about a quarter of a mile. She also had recently been
feeling very tired in general.

On [**2135-4-18**] the patient had an ETT Thallium with
report which showed that the
patient exercised for 4Admission Date: [**2135-4-19**] Discharge Date: [**2135-5-4**]

Date of Birth: [**2135-10-27**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old
female with a history of coronary artery disease DISEASE status post
percutaneous transluminal coronary angioplasty stent of the
right coronary artery in 5/99 and catheterization in 3/[**2132**].
She was doing well without chest pain DISEASE but had dyspnea DISEASE on
exertion for one to two months and recently felt fatigued.
She had a positive ETT and thallium test on [**4-18**] which
revealed 2 to [**Street Address(2) 2051**] depressions DISEASE inferolaterally and chest
pain DISEASE at 4.5 minutes of exercise. She underwent a cardiac
catheterization at [**Hospital1 69**] on
[**4-19**] which showed good ejection fraction and trace mitral
regurgitation of left ventricular short LMCA two serial 60
to 70% lesions in the mid left anterior descending coronary
artery 85% at the origin of the large diagonal artery 60%
origin at the high diagonal almost to the ramus 95% lesion
of the origin of the obtuse marginal one 95% LCX after
obtuse marginal one effecting more distal second obtuse
marginal distal AV groove LCX occlusion DISEASE before PLV branch DISEASE .
Mild mid right coronary artery lesion DISEASE 90% lesion just before
very large PDA which is collateral source to LCX DISEASE and left
anterior descending coronary artery diagonal territory.

PAST MEDICAL HISTORY:
1. Coronary artery disease status post percutaneous
transluminal coronary angioplasty stent of right coronary
artery in 5/99. Status post catheterization in 3/[**2132**].
2. Hypertension DISEASE .
3. Meniere's disease DISEASE .
4. Hysterectomy.
5. Transient ischemic attack 25 years ago.
6. High cholesterol.

HOME MEDICATIONS:
1. Ecotrin 25 mg po q.d.
2. Lopressor 100 mg po b.i.d. and 50 po q.h.s.
3. Diovan 160 mg po q day.
4. Lipitor 40 mg po q day.
5. Premarin .6 mg po q.d.
6. Meclozine 12.5 mg po q.d.

FAMILY HISTORY: Positive for coronary artery disease DISEASE .

SOCIAL HISTORY: She is and has been always a nonsmoker. No
alcohol. The patient lives alone.

ALLERGIES: Diuril.

PHYSICAL EXAMINATION: In general the patient is in no acute
distress. AVSS. HEENT normocephalic atraumatic. Pupils
are equal round and reactive to light. Extraocular
movements intact. Oropharynx benign. Neck supple. Full
range of motion. No lymphadenopathy DISEASE or thyromegaly DISEASE .
Carotids 2Admission Date: [**2135-4-19**] Discharge Date: [**2135-5-5**]

Date of Birth: [**2064-10-26**] Sex: F

Service:

ADDENDUM
The patient was kept one more night secondary to small apical
pneumothorax DISEASE after chest tube placement. The chest tube was
briefly put back to suction and then discontinued. A
post-discontinuation chest x-ray showed no pneumothorax DISEASE . She
is being discharged today in good condition.




[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 3113**]

Dictated By:[**Last Name (NamePattern1) 1332**]
MEDQUIST36

D: [**2135-5-5**] 09:26
T: [**2135-5-5**] 09:24
JOB#: [**Job Number 5921**]
Admission Date: [**2141-9-27**] Discharge Date: [**2141-9-28**]


Service: SURGERY

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
RUQ pain DISEASE .

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
[**Age over 90 **]M with multiple medical co-morbitities including Afib DISEASE BPH s/p
TURP x 3 CRI who presented to the ED this morning after being
found short of breath in his nursing home with RUQ pain DISEASE . On
arrival at [**Hospital1 18**] ED patient was found have RR in the 50's and
SBP in the 60s. Patient was emergently intubated and started on
neo gtt and levophed gtt. ED ordered a CT scan which showed
likely gangrenous cholecystitis DISEASE with intrabdominal free air.
Surgery was emergently consulted for further management.

Past Medical History:
Dementia Hypertension Chronic kidney disease DISEASE BPH with
overflow incontinence DISEASE Urinary retention Prostate cancer
Inguinal hernia Iron deficiency anemia UGI bleed Glaucoma DISEASE
Stasis dermatitis DISEASE and superficial ulcerations Lymphedema AFib DISEASE

PSH DISEASE : TURP [**3-21**]

Social History:
Lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. They provide meals. Denies smoking
social drinking. Used to be a designer of clothes had his own
company. Per reports from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] unable to walk on his
own and requires assistance for the majority of his other ADL's
(but is able to use the bedpan and feed himself).

Family History:
Patient unsure age parents passed away. Has many siblings (7 or
8) four of whom are still alive.

Physical Exam:
T 99.8 P 90 BP 120/70 ACV 450 x 20 .50 FIO2 on neo gtt Admission Date: [**2167-1-30**] Discharge Date: [**2140-3-14**]

Date of Birth: [**2125-10-11**] Sex: F

Service:

HISTORY OF PRESENT ILLNESS: [**Known lastname 5923**] is a 41-year-old female
with past medical history of questionable chronic obstructive pulmonary disease DISEASE and asthma DISEASE with two recent hospitalization
for asthma DISEASE / chronic obstructive pulmonary disease DISEASE flares
complicated by pneumonia DISEASE . Patient presents with five days of
URI symptoms sore throat DISEASE and fatigue DISEASE three days of
shortness of breath DISEASE with inhaler use with moderate relief
two day history of cough dry DISEASE and nonproductive and
subjective fevers DISEASE and chills DISEASE . Patient denies myalgias DISEASE
headache DISEASE chest pain rash diarrhea DISEASE abdominal discomfort
or hemoptysis DISEASE . Current symptoms are identical to prior
admission. Patient's last admission was on [**11-15**]. Patient
has one lifetime history of intubation. Patient had a lung
biopsy in [**9-15**] past reports suggestive of interstitial pulmonary fibrosis DISEASE .

On presentation to the Emergency Department patient had a
temperature of 101.9 F heart rate of 126 blood pressure
156/85 breathing rate of 28 saturating at 83% on room air.
Patient was put on oxygen. Patient received a chest x-ray
which showed questionable early left lower lobe infiltrate
with atelectasis DISEASE . EKG showed patient in sinus tach with poor
R wave progression left axis deviation no signs of
ischemia DISEASE . Patient was started on antibiotics steroids nebs
and admitted.

PAST MEDICAL HISTORY:
1. Interstitial pulmonary fibrosis DISEASE .
2. Adult onset asthma DISEASE with one lifetime intubation multiple
hospitalizations.
3. History of VRE DISEASE and MRSA.
4. Schizoaffective disorder.
5. Depression.
6. Multiple suicide attempts.
7. Temporal lobe epilepsy DISEASE .
8. Meningitis.
9. History of positive PPD status post six month treatment
with INH and Rifampin.
10. Gastroesophageal reflux disease DISEASE .
11. History of TDs in the setting of ETOH withdraw.
12. Exploratory laparotomy for abdominal mass DISEASE versus uterine
cyst DISEASE .
13. Noninsulin dependent diabetes mellitus DISEASE .

ALLERGIES:
1. Patient has insensitivity DISEASE to Codeine which gives her GI
upset.
2. True allergy DISEASE to Penicillin for which she gets a rash DISEASE .
3. Erythromycin for which she also gets a rash DISEASE .

MEDICATIONS:
1. Prozac 60 mg p.o. q. day.
2. Neurontin 1200 mg p.o. t.i.d.
3. Clozaril 100 mg q. AM 400 mg q. PM.
4. Flovent two puffs b.i.d.
5. Albuterol nebs p.r.n.
6. Risperdal 2 mg p.o. q.h.s.

SOCIAL HISTORY: Patient smokes one to two packs of
cigarettes per day and has a history of medical noncompliance
and poor follow up. Patient has been sober for greater than
10 years. Also prior use of LSD cocaine and heroin use but
none in the recent past. Patient lives alone.

PHYSICAL EXAMINATION: On arrival to the medical floor the
patient had a temperature of 98.3 F blood pressure 120/68
pulse of 100 respirations 22 saturating 94% on 10 liter
mask. In general patient is an obese white female in mild
distress able to speak in full sentences. Normocephalic
atraumatic. Pupils equal round and reactive to light.
Extraocular movements DISEASE intact. Oropharynx is clear. Neck was
supple without tenderness DISEASE or rigidity DISEASE . No jugular venous
distention was appreciated. Lungs: Decreased breath sounds
in the right base with mild wheezing DISEASE . Cardiovascularly:
Patient was tachycardic S1 S2 no murmurs. Abdomen was
obese soft nontender nondistended with normoactive bowel
sounds. Extremities: 1Admission Date: [**2121-5-18**] Discharge Date: [**2121-5-27**]

Date of Birth: [**2086-12-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Codeine / Nsaids / Levaquin

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Shortness of Breath DISEASE

Major Surgical or Invasive Procedure:
defibrillation

History of Present Illness:
34 yo woman with h/o hypertrophic CMY DISEASE multifocal atrial
tachycardias DISEASE s/p failed PVI [**3-21**] c/b pericardial tamponade c
window c/b PEA arrest x 45 minutes [**3-21**] with temporary CVVHD
and recent admission for SOB treated for volume overload DISEASE who
was admitted with chief complaint of shortness of breath DISEASE and
chest pain DISEASE . Initial vitals in ED showed T 97 HR 55 BP 124/66
RR 19 with o2 sat 100% on 4L. Pt. being evaluated by resident
in ED denying CP when she acutely c/o dyspnea DISEASE and was noted to
have wide complex rhythm on tele and lost pulse. Given 2 rds
epi 1 rd atropine 2 rds bicarb/ca chloride/insulin/D50 for
presumed hyperkalemia DISEASE as initial EKG showed sine wave pattern.
Also given 2L IVFs. She was coded for 30 minutes after which she
regained pulse and EKG showed NSR with wide complex with RBBB.
Initial BP 202/68. She then developed wide complex ventricular
tachycardia DISEASE with BP 68/p for which she was defibrillated X 1
200J and started on dopamine. At that point she returned to NSR
and was quickly weaned off dopamine gtt.
.
She had non-sterile R femoral line placed for access. Initial
labs (during code) showed K 5.5 on ABG (unclear if before or
after tx. for hyperkalemia DISEASE ) with ABG of 6.92/63/50. Bedside TTE
without pericardial effusion DISEASE . CXR showed new RAdmission Date: [**2121-6-14**] Discharge Date: [**2121-6-16**]

Date of Birth: [**2086-12-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Codeine / Nsaids / Levaquin

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
transfer from [**Hospital1 1474**] with rapid atrial rhythm hypotension DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a complicated 34 year old woman with hypertrophic
nonobstructive cardiomyopathy atrial tachyarrhythmias DISEASE PVI for
AF complicated by R atrial perforation DISEASE and clot in pericardium
with recent VF arrest DISEASE with prolonged CPR and subsequent
admission to [**Hospital1 18**] [**Date range (1) 5932**]. The patient was discharged to home
on [**5-27**] and did well for about one week per her report. She then
developed increased lower extremity edema DISEASE bilaterally as well as
left hand swelling DISEASE per her report. She felt that she might be
volume overloaded so she presented to [**Hospital 1474**] Hospital on [**6-3**].
States she was minimally active (using wheelchair/bedside
commode) but she was trying to be as active as possible.

On admission to [**Hospital1 1474**] INR was supratherapeutic 5.8 which
increased to 7.2 on [**6-5**]. She was treated with various
medications (zaroxolyn lasix IV & PO) for volume overload DISEASE . CT
of the chest demonstrated large right-sided pleural effusion DISEASE and
right-sided infiltrate. On [**6-9**] right-sided thoracentesis was
performed with removal of 1300 cc fluid. Initially treated with
ceftriaxone/azithromycin for pneumonia DISEASE changed to
azithromycin/cefuroxime on [**6-6**]. She was diuresed Admission Date: [**2175-7-11**] Discharge Date: [**2175-7-29**]

Date of Birth: [**2114-2-8**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with
a past medical history significant for right upper lobe small
cell cancer stage III status post chemotherapy and
radiation status post right upper lobe sleeve resection
[**6-19**] also with past medical history significant for diabetes DISEASE
mellitus hypertension prostate cancer DISEASE status post radical
prostatectomy GERD TIA DISEASE 15 years ago gout DISEASE and COPD DISEASE . The
patient has no known drug allergies DISEASE . The patient is status
post right upper lobe lung sleeve resection on [**6-19**] for small
cell lung cancer DISEASE . The patient was discharged home doing well
until four days prior to admission when he presented to the
Emergency Room with shortness of breath DISEASE and fevers DISEASE . The
patient was given Levaquin and was then discharged home
again. He continued having shortness of breath DISEASE and
productive cough DISEASE . He was admitted [**7-11**] for a follow-up
bronchoscopy during which time they found a right middle lobe
obstruction secondary to swelling DISEASE . After the procedure the
patient had shortness of breath DISEASE with an oxygen saturation of
88 as well as rigors DISEASE and chills DISEASE . The patient was also found
to have poor color. The patient's O2 saturation improved.
Chest x-ray was obtained and the patient was admitted. The
patient underwent surgery [**2175-7-15**]. The patient underwent
completion pneumonectomy bronchoscopy and serratus flap
closure of right main stem bronchus.

Postoperative day #1 the patient was afebrile with heart rate
of 56 blood pressure 104/56 satting at 99%. Chest tube
output 500 cc. Last gas 7.33 56 152 31 and 100%. On exam
lungs were clear to auscultation bilaterally. Incision
dressings were clean dry and intact. Heart was regular rate
and rhythm. Abdomen was soft nontender non distended.
Extremities had no swelling DISEASE . White count 13.4 hematocrit
38.5 platelet count 394000 potassium 4.8 BUN 13
creatinine .6 with glucose of 188 magnesium 1.8 and CPK of
1410. Plan was to wean the oxygen and check an ABG later on
and continue the pneumonectomy tube. To check an EKG because
of the EKG change this morning in which patient had ST
segment elevations undergo rule out MI protocol.

Postoperative day #2 the patient had no events over the last
24 hours patient remained afebrile. Heart rate 60 normal
sinus rhythm blood pressure 105/58 satting at 97% on four
liters last gas 7.39 52 96 33. Laboratory data revealed
white count 13.2 hematocrit 33.8 platelet count 322000 PT
12.9 PTT 25.7 INR 1.1 potassium 4.7 BUN 15 creatinine .5
with glucose 158 and magnesium 1.7. CK 840. Chest x-ray
pending. Physical exam was benign. Plan was to administer
Lasix today after transfer to the floor. Infectious disease
came by to see the patient postop day #2 as well because they
were requested to recommend an antibiotic for the right
infiltrate to prevent the possibility of a postoperative
empyema DISEASE . Their recommendation was to continue with the
current IV antibiotics. Clindamycin and Ceftriaxone will be
present. In the remote chance of postoperative infection DISEASE
empyema DISEASE these antibiotics will be present in the cavity and
also by peripheral circulation.

Postoperative day #3 events over the last 24 hours include
atrial fibrillation DISEASE . Patient mildly febrile DISEASE at 99.2 heart
rate 57 and sinus rhythm blood pressure 102/42 respirations
14 satting at 97% on four liters last gas 7.47 46 86 34
8 and 97%. White count 10.9 hematocrit 31.5 platelet count
331000 INR 1.1 PTT 28 potassium 3.9 BUN 14 creatinine
.5 glucose 141. Physical exam was benign. Plan was to
check the PT PTT and to get a chest x-ray today and to
continue 20 mg of Lasix. ID came by to see the patient again
today at which time they stated that the patient is already
on broad coverage for the lung abscess DISEASE . Strep and staff
improving the tubes will be discontinued after the
antibiotics. Follow-up of sensitivities on the culture and
anticipate a three week course of antibiotics.

Postoperative day #4 events overnight include a bronchoscopy
which was negative for fistula DISEASE . Stump was intact positive
secretions. The patient remained afebrile with a heart rate
of 57 sinus rhythm sinus brady DISEASE . Blood pressure 136/68
satting at 100% on 4 liters nasal cannula. White count 8.8
hematocrit 29.8 platelet count 375000 cultures from [**7-15**]
grew out streptococcus coag positive staph. Physical exam
was benign. ID again came by to see the patient at which
time they stated that they were awaiting final staph aureus
sensitivities before providing the direction of therapy.

Postoperative day #5 the patient remained afebrile heart
rate 65 and sinus blood pressure 106/60 satting at 95% on
room air. Chest tubes were discontinued. Urine output 1700.
Physical exam was benign. White count 10.9 hematocrit 31.5
platelet count 337000 potassium 3.9 BUN 14 creatinine .5
with a glucose of 141 magnesium 2.1.

Postoperative day #6 on Ceftriaxone and Clindamycin overnight
events include atrial fibrillation DISEASE and heparinization for
possible PE and a chest CT scan. Patient on Amio and
Heparin afebrile heart rate 108 and atrial fibrillation DISEASE
blood pressure 96/68 satting at 97% on three liters.
Hematocrit 37 PTT 28.4 potassium 4.2. Physical exam lungs
were irregularly irregular otherwise unremarkable.

Postoperative day #7 the patient remained afebrile heart
rate 56 blood pressure 109/65 satting at 97% on two liters.
On Lopressor Lasix Ceftriaxone Clindamycin and Amiodarone
PTT of 28. Physical exam unremarkable. The day prior the
patient underwent a spiral CT of the chest to rule out a PE.
There was radiographic evidence for peripheral pulmonary
emboli in the left lung patient on Heparin. ID again came
by to see the patient at which time they stated that the
patient was clinically stable from an ID perspective and to
continue the antibiotic regimen for a total of 14 days. If
the patient spikes a fever DISEASE they were to be consulted again.

Postoperative day #8 the patient remained afebrile vital
signs stable blood pressure 116/74 satting at 99% on 4
liters. Exam was benign. Plan was to check the PTT.
Patient is still on Heparin.

Postoperative day #9 the patient remained afebrile with a
heart rate of 63 and sinus rhythm respirations 18 satting
at 96% on 3 liters blood pressure 122/70. The patient was
on Heparin Lopressor Amiodarone Clindamycin Ceftriaxone
and Coumadin. On physical exam exam was benign. Plan was
to check the INR PTT and to continue aggressive pulmonary
PT. Postoperative day #9 overnight events include atrial
fibrillation DISEASE times one and an unchanged cough DISEASE . The patient
remained afebrile with heart rate of 55 and sinus brady DISEASE
respirations 20 satting at 95% on three liters blood
pressure 139/88 white count 9.7 hematocrit 33 platelet
count 490000 potassium 4.6 BUN 8 creatinine .6 and
glucose 115. Patient on Heparin Coumadin Lopressor
Amiodarone Lidocaine Xanax. Exam still remained unchanged.

Postoperative day #10 overnight events included atrial
fibrillation DISEASE and a cough DISEASE which is improving. The patient was
afebrile heart rate 63 respirations 22 satting at 90% on
three liters with a blood pressure of 149/78 hematocrit
34.6 BUN 8 creatinine .6 PT 16.5 PTT 83.5 with INR 1.8.
Patient on Heparin Lidocaine Coumadin Xanax Amiodarone.
Exam decreased breath sounds with crackles of the chest.
Continue current management.

Postoperative day #11 the patient remained afebrile with a
heart rate of 62 respirations 18 satting at 94% on two
liters blood pressure 96/59 white count 8.5 hematocrit 30
PT 17.6 PTT 113 INR 2.1. Patient on Coumadin Lopressor
Amiodarone Xanax and Lidocaine. Exam remained unremarkable.
Plan was to set up home VNA and chest x-ray today.

Patient was discharged on [**2175-7-29**].

DISCHARGE DIAGNOSIS:
1. Right middle lobe abscess.

DISCHARGE MEDICATIONS: The patient was stable on discharge
and was discharged home on the following medications:
Percocet 1-2 tablets po q 4 hours Robitussin AC 10 cc po q 4
hours Ambien 10 mg po q h.s. Glyburide 5 mg po q a.m.
Amiodarone 400 mg po tid for two days then 400 mg po bid for
7 days then 400 mg po q a.m. for 7 days Lopressor 12.5 mg
po bid Coumadin 2.5 mg po q h.s. and adjust to keep the INR
around 2 to 2.5.




[**Known firstname 177**] [**Last Name (NamePattern4) 178**] M.D. [**MD Number(1) 179**]

Dictated By:[**Doctor Last Name 182**]

MEDQUIST36

D: [**2175-10-11**] 11:01
T: [**2175-10-12**] 12:51
JOB#: [**Job Number 183**]
Admission Date: [**2121-10-29**] Discharge Date: [**2121-11-10**]

Date of Birth: [**2086-12-16**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Codeine / Nsaids / Levaquin

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath DISEASE .

Major Surgical or Invasive Procedure:
Right and left heart catheterization.
Endomyocardial biopsy.

History of Present Illness:
Mrs. [**Known lastname **] is a 34 year old woman with a history of
hypertrophic cardiomyopathy hypertension SVT DISEASE s/p PEA arrest DISEASE
x3 s/p pericardial effusion/window who was transferred to [**Hospital1 18**]
from [**Hospital 1474**] Hospital for CHF DISEASE exacerbation and work up for
constrictive pericarditis DISEASE . She reports she developed bilateral
back pain DISEASE with inspiration about 2 days ago that is consistent
with her prior CHF DISEASE exacerbation. She also reports that she
noticed that her face and lips became cyanotic with exertion at
home. Of note she reports she has a baseline variable 02
requirement at home from 0-2L. She otherwise denies f/c/change
in appetite CP/palp/SOB/Admission Date: [**2117-1-16**] Discharge Date: [**2117-1-25**]

Date of Birth: [**2072-1-20**] Sex: M

Service: [**Year (4 digits) 662**]

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
DOE/AMS

Major Surgical or Invasive Procedure:
PD DISEASE
BAL
Intubation
CVVHD
Central Line placement


History of Present Illness:
44 yo male with history of HIV (CD4 202 VL 27200 in [**5-3**])
ESRD DISEASE [**12-31**] HIV nephropathy CHF DISEASE (EF 25%) who presents with dyspnea DISEASE
on exertion. Pt was very lethargic when I interviewed him due to
recent ativan dose. States he has been having shortness of
breath on and off for the last week. Denies any chest pain DISEASE
palpitation DISEASE increasing LE edema orthopnea DISEASE PND. States he has
been doing his PD 5 times a day as directed last done at 3pm and
diasylate still in peritoneal cavity. Admits to recent crack
cocaine use but could not give details. Also admits to drinking
[**11-30**] pint- 1 pint liquor per day. Last drink within past 24
hours. States he has had recent fevers DISEASE . Denies DISEASE any nausea DISEASE
vomiting DISEASE . Positive non-bloody diarrhea DISEASE for several days. Was
arrousable only to pain DISEASE by the time MICU resident evaluated him
- he had been given 4 mg ativan IV as he was confused agitated
hypertensive DISEASE and tachycardic in the ED - this concerning for
ETOH W/D. As such MICU was called to evaluate him and he was
accepted on MICU service.

Past Medical History:
- HIV Admission Date: [**2187-4-20**] Discharge Date: [**2187-4-23**]

Date of Birth: [**2106-8-2**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5973**]
Chief Complaint:
Shortness of breath DISEASE altered mental status

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Patient is an 80 year-old patient with history of Sjogren DISEASE 's
syndrome moderate MR DISEASE recent hospitalization for sepsis DISEASE
secondary to c. diff colitis DISEASE complicated by hypercarbic DISEASE
respiratory failure DISEASE requiring intubation who is presenting from
[**Hospital 100**] Rehab with worsening dyspnea DISEASE for one day. Patient was
discharged from [**Hospital1 **] yesterday ([**2187-4-19**]) following hospitalization
for c. diff colitis DISEASE . Patient had ABG at [**Hospital 100**] Rehab which was
7.4/73/63. Her vitals on transfer were 97.9 99 24 113/68 92%
2L. She reports shortness of breath DISEASE associated with the cough DISEASE .
She denies chest pain DISEASE . She denies nausea DISEASE or vomiting DISEASE . She denies
abdominal pain DISEASE .

In the ED initial vitals are 100.2 95 99/47 28 100% 4L nc.
Exam was notable for tachypnea DISEASE with respiratory rates in the
30s. While in ED blood pressure dipped to 80s but improved on
it's own. Given the tachypnea cough DISEASE and dyspnea DISEASE there was
concern for pneumonia DISEASE . Patient received vancomycin and
levofloxacin. CXR appeared improved from most recent CXR.
Patiwnt was started on BIPAP. Patient underwent CTA to evaluate
for PE prior to leaving ED. On transfer vitals are HR 93 BP
109/45 O2 sat 100% on BIPAP.

On arrival to the MICU patient is wearing BiPAP but wants it
removed and does not want any other supplemental oxygen. She
denies pain DISEASE . She denies cough DISEASE or shortness of breath DISEASE .

Review of systems:
Unable to obtain patient wearing BiPAP and is delerious.


Past Medical History:
Anemia DISEASE
Borderline cholesterol
C. Diff
Flatulence
Health Maintenance
Heart Murmur
Hypertension DISEASE
Hypothyroidism DISEASE
Mitral Regurgitation
Osteoporosis DISEASE
Pneumonia DISEASE
Sinusitis DISEASE
Sjogren DISEASE


Social History:
Patient previously lived alone in an apartment and cares for
herself. Currently living at rehab after recent discharge. She
does not use tobacco or alcohol.

Family History:
Long history of hypertension DISEASE in her family. She does report
that her father's family has a history of multiple cancers DISEASE . She
has a grandfather with a history of stomach cancer DISEASE and an uncle
with a history of throat cancer DISEASE . She denies any history of
colon cancers DISEASE . Father had stroke DISEASE . No family h/o MI. Mother had a
heart valve replaced (pt not sure which one).


Physical Exam:
Exam upon admission:
General: Awake interactive but delerious. Not oriented to
place or time calling out trying to get out of bed. Cachetic
frail elderly female.
HEENT: Sclera anicteric dry mucus membranes.
Neck: supple JVP not elevated no LAD
CV: Regular rate and rhythm normal S1 Admission Date: [**2187-5-1**] Discharge Date: [**2187-5-12**]

Date of Birth: [**2106-8-2**] Sex: F

Service: MEDICINE

Allergies DISEASE :
meropenem

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypercarbic Respiratory Failure DISEASE

Major Surgical or Invasive Procedure:
Mechanical Intubation Arterial -Line Central Venous Access
Line

History of Present Illness:
This is an 80 year old woman recently hospitalized for C.
Difficile sepsis DISEASE and shock DISEASE complicated by readmission
hypoxia/hypercarbia ([**Date range (1) 5975**]) who presents with respiratory
distress and respiratory failure DISEASE .
.
The patient had reportedly been doing well in rehab until today
when she was noted to have an altered ( depressed DISEASE ) mental status
tachypnea DISEASE and dyspnea DISEASE . EMS was called who found the patient in
extremis intubation was attempted x2 and failed. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] airway
was placed and the patient was transported to [**Hospital1 18**] emergency
department. There were no reports of increased coughing or
stooling from [**Hospital 100**] Rehab.
.
The patient has had a complicated medical course in the past
month -
.
In brief the patient was initially discharge on [**4-19**] after
a 14 hosptilazation for c.diff colitis complicated by sepsis DISEASE and
hypercarbic respiratory failure DISEASE requiring intubation. On the
day following discharge from that admission the patient was
noted to be complaining of worsening SOB and ABG at [**Hospital 100**] rehab
was 7.4/73/63. She was re-admitted to [**Hospital1 18**] on [**4-20**] to the MICU
and intially reuqired biPAP for HD1-2. Her oxygen requirement on
d/c was 2L NC. The etiology of her hypercarbic respiratory
failure DISEASE was felt to be [**12-21**] hypoventilation DISEASE from somnolence DISEASE
related to oversedation with zyprexa which was held on
discharge. A CTA chest was negative for PE and showed no clear
evidence of pneumonia DISEASE . She was initially started on HCAP DISEASE
antibiotics with vanc/cefepime which were stopped on HD 4 prior
to discharge given that all cultures were negative and there was
no consolidation on imaging.
.
In the ED initial VS were: HR: 82 BP: 94 systolic Resp: No
spontaneous respirations O(2)Sat: 100Admission Date: [**2180-4-16**] Discharge Date: [**2180-4-20**]

Date of Birth: [**2149-1-31**] Sex: M

Service: MED


CHIEF COMPLAINT: Abdominal pain.

This is a 31-year-old gentleman with longstanding history of
Crohn's disease DISEASE since age 12 years status post ileo
resection and ileocolic anastomosis. The patient was
recently admitted in [**2179-12-16**] for a Crohn's DISEASE flare and has
been on the steroid taper since his discharge. One week
prior to admission his prednisone was decreased from 20 mg
to 10 mg and on the day prior to admission the patient
developed mild discomfort in his abdomen then extreme pain DISEASE
with nausea DISEASE and vomiting DISEASE today. The patient denied any
diarrhea DISEASE or bright red blood per rectum. His last bowel
movement was this morning. The pain DISEASE is located in the
periumbilical area radiating diffusely. Of note the patient
has a new rash DISEASE that started in his ears as mild pruritus DISEASE . He
noted what was thought to be pimples DISEASE that exposed to mild
fluid initially in his ear. The rash DISEASE has not progressed to
his neck back and chest. The patient has had recent travel
to [**Country 5976**] but is not fully coming about the details of his
trip.

Of note the patient was given morphine in the ED for pain DISEASE
control and developed urinary retention DISEASE .

PAST MEDICAL HISTORY: Crohn's disease DISEASE times 12 years. The
patient has had immunosuppression with 6-MP and has also been
recently on the steroid taper.

Ileal resection with ileocolic anastomosis and small bowel
stricture DISEASE .

Iron deficiency anemia DISEASE .

Lactose intolerance DISEASE .

Status post appendectomy.

Colonoscopy in [**2179-2-13**].

Prior cryptococcal infection DISEASE involving spleen.

ALLERGIES: No known drug allergies DISEASE .

CURRENT MEDICATIONS:
1. Prednisone 10 mg q.d.
2. Protonix 40 mg q.d.
3. 6-MP 100 mg q.h.s.
4. Methenamine 250 mg four capsules q.i.d.
5. Entocort 9 mg p.o. q.d.
6. Imodium one capsule t.i.d.


SOCIAL HISTORY: Smokes half pack per day. He has been a
smoker since [**20**] years. The patient drinks one to two beers
per day.

PHYSICAL EXAMINATION: On admission vital signs temperature
97.0 heart rate 80 and blood pressure 135/75. Generally
the patient was uncomfortable appearing but in no acute
distress. HEENT: Moist mucous membranes. Oropharynx is
clear. Pupils equal round reactive to light. Extraocular
movements are intact. Neck was supple without
lymphadenopathy DISEASE . Cardiovascular: Regular rate. S1 and S2.
No murmurs rubs or gallops. Pulmonary: Clear to
auscultation bilaterally. Abdomen: Normal bowel sounds
soft mild pain DISEASE on palpation in the periumbilical region. No
significant distention. No rebound or guarding.
Extremities: No clubbing cyanosis DISEASE or edema DISEASE . Two plus
pulses bilaterally. Neurologically: Alert and oriented
times 3. Skin exam shows 2-3 mm papules over neck back and
chest. Mildly pruritic DISEASE and nontender.

LABORATORY DATA: Labs on admission white blood count was
5.4 with 86 neutrophils 11 bands and 1 plasma cell.
Hematocrit was 40.1 and platelets are 246. chemistry sodium
141 potassium 4.3 chloride 105 bicarb 26 bun 8
creatinine 0.7 and glucose 109. ALT is 150 AST 90
alkaline phosphatase 58 LDH 328 total bilirubin is 1.1
lipase 20 and amylase 63. UA was negative. CT of the
abdomen and pelvis showed prominence of small bowel with mild
thickening DISEASE and a very few short segments. Less extensive
thickening DISEASE than in [**2179-12-16**]. No evidence of obstruction DISEASE .

HOSPITAL COURSE: This is a 31-year-old male with abdominal
pain DISEASE initially thought to be a Crohn's DISEASE flare. However over
the next 24 hours after admission the patient developed
hypoxia DISEASE and respiratory distress DISEASE as well as worsening
abdominal pain DISEASE . On the following day after admission again
clinical course was declining. The patient was seen by the
infectious disease GI DISEASE and hematology oncology consultants.
That night the patient did develop the transaminitis DISEASE with ALT
to 674 and AST 754 with an LDH of 861 and total bilirubin
1.6 pt 13.1 PTT 29.2 and INR of 1.1. D-dimer was found to
be greater than 10 000. At this time the transaminitis DISEASE in
the setting of the rash DISEASE was concerning for a viral etiology.
Hep serologies were checked in addition to CMV EBV and an
acute HIV infection DISEASE . Other serologies such as
toxoplasmosis cryptococcus DISEASE VDV and HSV were also
considered. There is a thought that the patient's
immunocompromised DISEASE status under section PN steroid use might
make him more susceptible to had seminate with zoster DISEASE . Again
that night the patient was started on vancomycin for
possible skin infection DISEASE and doxycycline for question of tick
borne diseases. on Cipro and Flagyl for a possible Crohn's DISEASE
flare on acyclovir for possible seminated zoster DISEASE and on
amphotericin for a possible histo DISEASE . Dermatology acutely saw
the patient on the night of [**2180-4-17**] and noted a
micropapular blenching rash DISEASE which was thought to be a viral
exanthem. TSA was performed showing evidence of varicella DISEASE
zoster DISEASE virus. Of note medical team was informed that the
patient had never had chickenpox DISEASE and this is a primary
disseminated varicella infection DISEASE . The hematology consult
obtained on the night of [**2180-4-17**] was on the setting of
thrombocytopenia DISEASE there was some concern for symptoms of
process such as a cord splenomegaly DISEASE or destruction by an
immune mediated system such as a viral infection DISEASE . Diagnosis
such as GIC HUS-TPP were considered. Coagulations had
currently been stable. A smear was reviewed and showed no
evidence of cystocytes and hypertension DISEASE was elevated. There
was again some concern for DIC and the patient's platelets
coagulations LDH and fibrinogen were followed closely.
Again that night the patient significantly decompensated and
had evidence of respiratory distress DISEASE . The patient was
transferred to MICU on the night of [**2180-4-17**].

Overnight in the MICU the patient remained relatively
stable. However he again have evidence of hyper and
hypothermia DISEASE . The patient's respiratory status remained
stable. However the patient began to require increasing
levels of oxygen. The patient's O2 saturation was
approximately 90 percent on a 10 liter V-stent. In addition
the patient was noted to be tachycardic with heart rate in
the 140s. On [**2180-4-18**] which is hospital day 3 but MICU
day 1 the patient was noted to have significant abnormality
in his labs. ALT increased to 35.73 AST increased 53.23
alkaline phosphatase just 180 and total bilirubin increased
to 5.8. There is evidence of mild renal failure DISEASE . Platelets
declined to 23 haptoglobin was less than 20 and fibrinogen
was 94.

At this point hepatitis DISEASE serologies returned negative
cryptococcal antigen was negative RPR was non-reactive CMC
was negative toxo was negative Histoplasma capsulatum
antigen was negative DFA for HSV DISEASE was negative. However DFA
for VZV DISEASE became positive and IgG for VZV DISEASE was negative
consistent with primary varicella infection DISEASE . At this point
the patient's antibiotics were readjusted. The patient was
given high doses of acyclovir. Other antibiotics were
discontinued. In addition secondary to respiratory
distress the patient was intubated for worsening hypoxia DISEASE .
After intubation the patient became hypotensive DISEASE and received
aggressive fluid resuscitation with 12 liters fluid
initially normal saline and subsequently lactate ringers.
The patient was started on Levophed for hypotension DISEASE and
despite full it does not remained around 55. The patient
subsequently became difficult to oxygenate and ventilator
settings were adjusted to maintain pao2 in 70s to 80s.

The patient's pulmonary status on hospital day 4 the patient
was significantly difficult to oxygenate. Paralytics were
used to help ease the work of breathing. The patient's chest
films and pao2 to fio2 ratio were consistent with ARDS. The
patient was proned to assist with improvements on oxygenation
and this initially helped. However the patient became
hypoxic again and was reproned. Regarding the patient's
liver failure DISEASE LFTS continued to rise chlorides continued to
rise and renal failure DISEASE worsened. The patient did have some
evidence of DIC DISEASE and was transfused cryo for fibrinogen less
than 100. The patient was continued to be treated with
acyclovir. However given repeated fevers DISEASE the patient was
also started on cefepime and on vancomycin. Regarding his
renal failure DISEASE and multiple issues the patient's acidosis DISEASE was
thought to be to secondary to shock DISEASE versus tissue necrosis DISEASE
versus renal failure DISEASE versus electrolyte abnormalities. The
vent was adjusted to compensate for pH. The patient was
given large doses of bicarbonates to adjust his acidosis DISEASE .
ABG at that time was 7.14 38 and 86.

Regarding his acute renal failure DISEASE the patient's bun and
creatinine continued to rise despite fluids. There was some
thought about initiating CVVH and ultimately a catheter was
placed by the renal team. On the hospital day next the
patient was significantly hypoxic with pao2 in 37 with
increasing difficulty to oxygenate. Prior to this time the
patient had been ruled in an esophageal balloon study to help
determine adequate peak. The patient secondary to ventilator
protective strategies under the Argonaut protocol the
patient had been receiving higher doses of PEEP to improve
oxygenation. However on this day the patient developed
evidence of pneumomediastinum DISEASE . The patient was proned with
slight improvements in his po2.

Other issues the patient's acidosis DISEASE continued to worsen.
His hypotension DISEASE however improved with the patient remained
pressor dependent. Further imaging was performed in order to
understand etiology of liver failure DISEASE . Ultrasound showed
clots in the portal vein decreased splenic vein flow patent
hepatic veins and IVC. The patient was started on low-dose
heparin. There is some concern that there is evidence of
hypercoagulable state. Again at this time the patient
remains intubated on four pressors with increasing difficulty
oxygenating. The patient's transaminases continued to rise
as well as coagulopathy DISEASE worsening and renal failure DISEASE
worsening. A lactate measured on this day was 26. Regarding
his problem his hypoxia DISEASE and respiratory failure DISEASE was thought
to be due to varicella pneumonitis DISEASE . The patient is on the
ventilator with Argonaut protocol in the setting of
pneumomediastinum DISEASE and there was concern for pneumothorax DISEASE .
At this point it was thought to put him prophylactic chest
tubes in the setting of the patient was to develop a
pneumothorax DISEASE . However the patient's clinical status
declined secondary to multisystem organ failure DISEASE before this
could be initiated.

The running of hypotension DISEASE and shockAdmission Date: [**2138-1-6**] Discharge Date: [**2138-1-14**]

Date of Birth: [**2074-6-8**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Tricor

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
pneumonia DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
63F with type 2 diabetes coronary artery disease DISEASE s/p CABG
presents with 2 days history of productive cough shortness DISEASE of
breath fever/chills and L-sided pleuritic chest pain DISEASE . Chest CT
revealed dense multi-lobular L PNA. Patient was intubated in ED
because of increasing respiratory effort. Approximately 30mins
after intubation she became hypotensive DISEASE with mean arterial
pressure in high 50s requiring levophed. Sepsis protocol was
initiated & patient was given empiric ceftriaxone Azithromycin
and Vancomycin. Initial labs were notable for a WBC of 7.6 with
18% bands INR 1.8 Mg 1.1 fibrinogen 700 lactate 5.1 trending
down to 2.3 after 4L NS. EKG was without acute changes and CE x
1 negative. Sputum GS revealed 4Admission Date: [**2189-9-30**] Discharge Date: [**2189-10-2**]

Date of Birth: [**2127-4-7**] Sex: M

Service: [**Hospital Unit Name 196**]

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
ELECTIVE CAROTID ANGIOGRAPHY AND LEFT INTERNAL CAROTID STENTING

Major Surgical or Invasive Procedure:
Bilateral Carotid Angiography and Left Internal Carotid Stenting


History of Present Illness:
Pt is a 62 y.o man w/ h/o CAD s/p Admission Date: [**2189-12-26**] Discharge Date: [**2190-1-6**]

Date of Birth: [**2127-4-7**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
chest pain shortness of breath DISEASE

Major Surgical or Invasive Procedure:
cardiac cath s/p stent to left main LAD DISEASE
IABP placement


History of Present Illness:
62 yr old male with 3VD CHF DISEASE 20-25% with 3-4Admission Date: [**2145-11-8**] Discharge Date: [**2145-12-6**]

Date of Birth: [**2084-11-22**] Sex: F

Service: NEUROLOGY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
[**Last Name (un) 4584**] [**Location (un) **] Syndrome

Major Surgical or Invasive Procedure:
5-days IVIG therapy


History of Present Illness:
The patient is a 60-year-old left-handed woman with a history of
chronic inflammatory demyelinating polyneuropathy DISEASE ( CIDP DISEASE ) from
which she recovered fully about 20 years ago who presents from
an outside hospital today with 2 days of
paresthesias DISEASE and one day of weakness DISEASE for evaluation of possible
[**Last Name (un) 4584**] [**Location (un) **] Syndrome. The patient reports that on [**10-28**] she
underwent a t-lith procedure and initially had made an excellent
recovery. However 2 days prior to presentation she noted that
she had tingling of the hands and feet with an abnormal
decreased sensation over the remainder of her upper and lower
extremities as though it were Admission Date: [**2109-3-19**] Discharge Date: [**2109-3-21**]

Date of Birth: [**2022-7-8**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Hyperglycemia DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname 4587**] is an 86 year old female with multiple medical
problems including bilateral unprovoked PE DISEASE 's on coumadin CAD
diabetes DISEASE on home insulin complicated by LE ulcers DISEASE who was
initially referreed into the ER by her VNA for hyperglycemia DISEASE .
She has been being seen every other day by a VNA for wound care
of her lower extremity ulcers DISEASE which per her report have been
improving and this morning she was noted to have a blood sugar
of 411. She says that she took her usual insulin regimen this
morning which is 6units of NPH and 20 units of regular.
Additionally she completed an empiric 10 day course of
ciprofloxacin 4 days ago which was prescribed by her podiatrist
for her lower extremity ulcers DISEASE however the dysuria DISEASE she had been
having improved but did not resolve. She says that at baseline
she is incontinent she continues to have dysuria DISEASE but thinks
that her urine output has actually decreased recently. She
thinks that her LE ulcers DISEASE have been improving she denies any
associated fever/chills n/v/d abdominal pain DISEASE leg pain DISEASE chest
pain DISEASE or shortness of breath DISEASE .

In the ED initial VS were: 99.4 57 110/44 16 100% on RA DISEASE .
She was initially alert and interactive but about 30min later
she was found to be much less interactive and her labs returned
with a blood sugar of 39 she was then given 1 amp of D50 with
improvement in her mental status and repeat FS was 238. At the
time of her hypoglycemia DISEASE she was also noted to feel cool to the
touch at which time a rectal temperature was done that was 35
degress celsius. Other than the hypoglycemia DISEASE her labs were
notable for a Cr of 2.9 from a baseline of 1.1-1.6 her INR was
6.0 lactate of 1.4 white count was 7.9 no bands but 1 meta
and 1 myelo U/A with 135 WBC's many bacteria trace blood and
30 protein. X-rays of her LLE did not show any evidnece of
osteomyelitis DISEASE and CXR did not show any evidence of pnuemonia DISEASE .
Additionally in the ER she had an episode of hypotension DISEASE to
78/35 which improved to SBP's in the 110's after 2LNS. She was
given ceftriaxone for the UTI DISEASE and vancomycin for possible
cellulitis DISEASE surrounding her LE ulcers DISEASE . VS on transfer: rectal
temp of 34.3C 55 111/63 17 95% on RA DISEASE .
.
On arrival to the MICU her initial VS were: 93.9 69 110/63
16 92% on RA DISEASE . She currently is denying any pain DISEASE her only
complaint DISEASE is that she continues to feel cold. She also says
that she has a chronic cough DISEASE that is unchanged.

Past Medical History:
1. Bilateral pulmonary embolism DISEASE of unknown etiology on
Coumadin.
2. Recent history of osteomyelitis DISEASE now treatment completed.
3. Diabetes mellitus DISEASE type 2.
4. Coronary artery disease DISEASE .
5. Hypertension DISEASE .
6. Hypercholesteremia.
7. Hyperthyroidism DISEASE .
8. Depression.


Social History:
The patient lives with her husband in [**Name (NI) 1468**]
and manages her activities of daily living as well as
instrumental activities of daily living without any problems.
She
has five sons all of whom live close by.


Family History:
The patient's mother died in her early 80s with Alzheimer's DISEASE
disease. Her father had tuberculosis DISEASE . No other significant
family history.


Physical Exam:
General: Alert oriented no acute distress
HEENT: Sclera anicteric MMM oropharynx clear EOMI PERRL
Neck: supple JVP not elevated no LAD
CV: Regular rate and rhythm normal S1 Admission Date: [**2175-9-18**] Discharge Date: [**2175-9-28**]

Date of Birth: [**2114-2-8**] Sex: M

Service: CCU/MEDICAL ICU/C-MEDICINE

HISTORY OF PRESENT ILLNESS: The patient is a 61 year old man
with a history of stage III squamous lung carcinoma DISEASE status
post lobectomy and pneumonectomy on the right earlier this
year who was transferred to [**Hospital1 188**] for respiratory failure DISEASE . Two weeks prior to
admission the patient began experiencing episodes of
shortness of breath cough DISEASE and dyspnea DISEASE . Echocardiogram and
electrocardiogram performed at that time were reportedly
unremarkable.

On [**2175-9-17**] after coming home from his son's wedding the
patient became acutely short of breath agitated and
collapsed on the floor stating that he could not breathe.
His family called 911 and the patient was intubated in the
field and taken to [**Hospital 189**] Hospital where a chest x-ray was
reportedly normal but electrocardiogram showed transient new
left bundle branch block DISEASE ST elevations in leads II through
V4 and Q waves in the anterior precordial leads all of which
was new. He was transferred to the [**Hospital1 190**] and Coronary Care Unit for further evaluation
and management.

PAST MEDICAL HISTORY:
1. Stage III-A squamous cell lung carcinoma DISEASE status post
right pneumonectomy chemotherapy and radiation.
2. Transient ischemic attack.
3. Pulmonary embolism DISEASE .
4. Atrial fibrillation DISEASE on Amiodarone.
5. Prostate cancer status post radical prostatectomy.
6. Diabetes mellitus DISEASE .
7. Negative exercise Thallium test in [**2175-2-26**].

ALLERGIES: The patient has no known drug allergies DISEASE .

MEDICATIONS ON ADMISSION:
1. Amiodarone 400 mg p.o. b.i.d.
2. Coumadin 3 mg p.o. q.h.s.
3. Oxazepam p.r.n.
4. Lopressor 12.5 mg p.o. b.i.d.
5. Glyburide 5 mg p.o. q.d.
6. Neurontin 100 mg p.o. t.i.d.
7. Ambien 10 mg p.o. q.h.s.

FAMILY HISTORY: The patient has a sister who died of cancer DISEASE
at the age of 39 and an older brother status post coronary
artery bypass graft. His father also had coronary artery
disease and a sister has cardiac valve disease DISEASE .

SOCIAL HISTORY: The patient quit smoking three months ago
following three to four packs per day times forty years. He
consumed two to three drinks per day. He is a construction
worker.

PHYSICAL EXAMINATION: On admission temperature is 99 heart
rate 70 to 80s blood pressure 110/60 oxygen saturation 95%.
In general the patient was intubated and sedated. Head
eyes ears nose and throat examination indicated the pupils
2.0 millimeters and reactive bilaterally. Endotracheal tube
is in place. Cardiovascular - tachycardia DISEASE with no murmurs
rubs or gallops. Pulmonary examination - The patient had
diffuse coarse rhonchi DISEASE on the left and absent breath sounds
on the right. The abdomen was soft nontender nondistended
with normal bowel sounds DISEASE . The extremities were warm with 1Admission Date: [**2109-10-16**] Discharge Date: [**2109-10-18**]

Date of Birth: [**2022-7-8**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
AMS

Major Surgical or Invasive Procedure:
None

History of Present Illness:
87 yo F with T2DM c/b peripheral neuropathy DISEASE CAD s/p stent
chronic anemia HTN DISEASE h/o PE on warfarin and other medical issues
presents from home with AMS.

Touched base with patient's PCP who states that patient has not
been doing well with slow decline and hospice option has been
entertained recently. She is supposed to have hospice nurse
visiting for initial evaluation on Monday. Patient has been
noted to be depressed DISEASE but mentating well at baseline.

Per patient's husband patient has not been eating well or
drinking well for the last few weeks. Her mental status
declined significantly over the last week. She has complained
about suprapubic pain DISEASE for the last few days. She had VNA on
Monday

Per EMS patient is arousable with verbal stimuli FSBS 311.
Patient appeared dry cool to touch.

In the ED inital VS were 97.8 72 148/104 22. Per report Admission Date: [**2108-3-20**] Discharge Date: [**2108-3-23**]

Date of Birth: [**2043-7-15**] Sex: M

Service: MEDICINE

Allergies DISEASE :
lisinopril

Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
fever DISEASE at dialysis

Major Surgical or Invasive Procedure:
Hemodialysis


History of Present Illness:
64M w/ h/o schizoaffective disorder DISEASE & ESRD DISEASE [**3-1**] lithium toxicity
admitted from [**Location (un) **] [**Location (un) **] for fever DISEASE at HD DISEASE in ED febrile to
104F w/tachycardia to 130s (sinus) admitted to ICU for possible
septic shock DISEASE source still unclear. CXR clear. UA clean. No
lineAdmission Date: [**2172-3-9**] Discharge Date: [**2172-3-14**]


Service: MEDICINE

Allergies DISEASE :
Morphine Sulfate

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
1. Intubation
2. Right Radial Arterial Line

History of Present Illness:
This is an 87-year-old woman with an extensive PMH including CAD
3 vessel HTN CHF DISEASE mod-severe AS who presented with acute
respiratory distress requiring intubation. Ms. [**Known lastname 4602**]
developed increasing dyspnea DISEASE at home since yesterday with
elevated blood pressure last evening (SBP Admission Date: [**2173-8-14**] Discharge Date: [**2173-8-26**]


Service: MEDICINE

Allergies DISEASE :
Morphine Sulfate

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
AMS shortness of breath DISEASE

Major Surgical or Invasive Procedure:
PICC line


History of Present Illness:
88yo F PMhx CHF HTN DISEASE presenting w AMS in the setting of a fall.
1d prior to presentation patient was getting out of bathtub
when she slippedAdmission Date: [**2117-4-15**] Discharge Date: [**2117-4-21**]

Date of Birth: [**2054-11-28**] Sex: M

Service: CCU

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: The patient is a 62 year old
male with HIV and coronary DISEASE risk factors including diabetes DISEASE
mellitus hyperlipidemia DISEASE family history of coronary artery
disease and male sex who presented to his primary care
physician with two months of progressive dyspnea DISEASE on exertion.
The patient had cardiac echocardiogram which showed ejection
fraction of 20% and 3Admission Date: [**2121-8-3**] Discharge Date: [**2121-8-6**]

Date of Birth: [**2040-10-31**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
80F Russian-speaking with hx of afib on coumadin HTN lung ca
s/p left pneumonectomy with recent fall and L humerus fx 3D
ago presents after fall Admission Date: [**2165-12-25**] Discharge Date: [**2166-1-8**]

Date of Birth: [**2084-3-20**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
chest pressure

Major Surgical or Invasive Procedure:
Cardiac cathetherization


History of Present Illness:
[**Known firstname 2127**] [**Known lastname 4612**] is a 81 yo female with a past medical history of
CAD with a 1 vessel CABG (SVG to LAD) in [**2134**] who presents with
chest pressure. She woke up at 8 am with substernal chest
pressure. It was severe initially. She took SL NTG x3 with
relief of CP for a short period of time. The CP radiated to her
right side and eventually down both arms. She reports
diaphoresis DISEASE but denied associated nausea vomiting DISEASE
lightheadedness or dizziness. She reports that she has felt
mildly SOB since her recent pneumonia DISEASE (first diagnosed appox [**6-24**]
weeks ago). She denied worsening dyspnea DISEASE . Her cough DISEASE has
improved substantially and is very minimal at this time. She
went to her PCP's office and was found to have a new LBBB DISEASE and
anterior ST elevations. She was transferred to the ED. She
received Plavix 300mg Aspirin boluses of heparin and
integrillin. Code STEMI was called and went to the cath lab.
Cath showed occluded SVG Native 3vd occluded proximal LAD.
Wiring the LAD was difficult and there was concern about a
possible dissection. One BMS was placed in the proximal LAD.
Distal LAD DISEASE is diminutive past 1st septal and diag branches.
She has been hemodynamically stable with HR 60-70s and SBP
120-130s. On the floor she is currently chest pain DISEASE free and
feels well.
.
.
On review of systems she denies any prior history of deep
venous thrombosis pulmonary embolism bleeding DISEASE at the time of
surgery myalgias joint pains cough hemoptysis DISEASE black stools
or red stools. She denies recent fevers chills DISEASE or rigors DISEASE . All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain DISEASE
dyspnea DISEASE on exertion paroxysmal nocturnal dyspnea orthopnea DISEASE
ankle edema palpitations syncope DISEASE or presyncope DISEASE .


Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes DISEASE Admission Date: [**2167-2-13**] Discharge Date: [**2167-2-19**]

Date of Birth: [**2084-3-20**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Difficulty in breathing

Major Surgical or Invasive Procedure:
none


History of Present Illness:
The patient is a 82 year-old female with a history of NSCLC DISEASE
(stage IV) who presents with shortness of breath DISEASE .
.
The patient was in her usual state of health until the evening
before admission when she began to feel somewhat short of
breath. The next morning this sensation persisted so she
became concerned. She also reports a few day history of a
non-productive cough DISEASE . Denies sick contacts recent travel or
sedentary lifestyle. She denied chest pain fever chills DISEASE
dizziness lightheadedness DISEASE or syncope DISEASE . She presented to the ED
where she was found to be hypoxic to the 70s on room air.
.
In the ED she was placed on a non-rebreather with sats up to
the high 90's. Attempts were made to wean her to NC but they
were unsuccessful as she was satting 88% on 4L NC. She
remained afebrile in the ED but was found to have WBC of 17.
Given that she received levofloxacin and vancomycin. Blood
cultures were drawn prior to antibiotic administration. CXR did
not show PNA but demonstrated progression of known lung cancer DISEASE .
She underwent a CT head to rule out metastases which was
negative. On transfer patient was afebrile with HR- 77 BP-
112/49 RR- 16 SaO2- 98% on 15L NRB
.
On transfer to the ICU the patient was stable and comfortable.
Sats were 97% on 5L NC and 95% high-flow with a face-tent.
.
ROS: The patient denies any fevers chills DISEASE weight change
nausea vomiting abdominal pain diarrhea constipation DISEASE
melena hematochezia chest pain orthopnea DISEASE PND lower
extremity edema cough DISEASE urinary frequency urgency dysuria
lightheadedness gait unsteadiness focal weakness vision DISEASE
changes headache rash DISEASE or skin changes.
.


Past Medical History:
CAD s/p MI [**2134**] s/p CABG [**2165**]
Hypertension DISEASE
Dyslipidemia DISEASE
CVA DISEASE : small left posterior frontal infarct DISEASE in [**12/2164**]
Macular Degeneration
NSCLC- stage IV (oncology history below)
.
-- [**12/2165**] presented in with unresolving right-sided pulmonary
infiltrate and an unrelated myocardial infarction DISEASE .
-- [**2166-1-2**] Sputumcytology confirmed adenocarcinoma DISEASE with a
pattern of stainpositivity consistent with lung origin (CK7 and
TTF-1 positive). She had stage IV nonsmall cell lung cancer DISEASE
based on the multiple intrapulmonary lesions. She has no
evidence of extrathoracic or central nervous system involvement
with metastasis DISEASE .
-- [**2166-1-7**]---Admission Date: [**2167-7-30**] Discharge Date: [**2167-7-31**]

Date of Birth: [**2084-3-20**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Dyspnea DISEASE and melena DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Ms. [**Known lastname 4612**] is a 83yo F with history of stage IV non-small DISEASE
cell lung cancer CAD and CKD DISEASE who presents with dyspnea DISEASE
productive cough DISEASE and melena DISEASE . Patient has had 7-8 days of melena DISEASE
without abdominal pain DISEASE and dyspnea DISEASE with worsening cough DISEASE for the
past day. She denies fevers DISEASE or chest pain DISEASE .
.
In the ER initial vitals were 97.2 89 156/53 22 86% 4L. Her
hct was 22 from recent baseline of 25 (she has transfusion
dependent anemia DISEASE ) and she initially was hypoxic. ABG was
7.29/64/42/32 and lactate was 2.4. Patient responded to nebs
stress dose steroids levaquin and ceftriaxone with improvement
in her sats to mid 90s on 5L NC. She was started on IV PPI for
her guaiac positive dark brown stool. CXR showed large R pleural
effusion and questionable L lower lobe collapse. EKG showed
sinus tach with ST depressions in V2-6. Vitals on transfer to
the MICU were 97.2 105 127/50 29 96% 5L NC.
.
In the MICU she reports feeling better after her breathing
treatments today. She cannot recall when her difficulty
breathing started and per her family she has difficulty hearing
but no memory loss DISEASE . Patient had intermittent dyspnea DISEASE for weeks
for which she previously took codeine syrup but then a period of
improvement. She developed worsening dypsnea and cough DISEASE yesterday
without fevers chills DISEASE or chest pain DISEASE . She denies prior history
of melena DISEASE but has had stable nausea DISEASE and poor appetite for
months. No heartburn DISEASE or dysphagia DISEASE .


Past Medical History:
Stage IV nonsmall cell lung cancer adenocarcinoma DISEASE EGFR
wild-type KRAS mutated
CAD s/p CABG in [**2134**] MI [**12-25**] s/p PCI to LAD.
Chronic renal insufficiency DISEASE - Patient with GFR Admission Date: [**2107-2-26**] Discharge Date: [**2107-2-27**]

Date of Birth: [**2040-5-3**] Sex: F

Service: Neurosurgery

HISTORY OF PRESENT ILLNESS: This is a 66 year old female who
was in her usual state of health until lunch on [**2-26**] when
she developed a sudden onset headache DISEASE visual changes and
nausea DISEASE . Emergency medical services was called and the
patient was transported to [**Hospital6 4620**] for
care. The patient was oriented times one and combative at
the outside hospital and was intubated there. The patient
was then transferred to the [**Hospital6 2018**] for further management. On computerized tomography
scan the patient had a large intracranial hemorrhage DISEASE in the
left parietal lobe measuring 6 cm with severe
midline shift.

PAST MEDICAL HISTORY: 1. HeadachesAdmission Date: [**2118-12-7**] Discharge Date: [**2118-12-9**]

Date of Birth: [**2073-12-25**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Skull defect

Major Surgical or Invasive Procedure:
s/p cranioplasty on [**2118-12-7**]


History of Present Illness:
44 yo female with a h/o left frontal AVM DISEASE in the supplementary
motor area. The AVM DISEASE was treated with stereotactic radiosurgery
(Gamma Knife)in [**2114**]. In [**2116**] the patient developed a seizure DISEASE
disorder DISEASE . [**2118-5-27**] she developed
headaches DISEASE and after an MRI and a digital angiogram showed no
residual pathological vessels a contrast enhancing lesion
with massive focal residual edema DISEASE was diagnosed- very
likely represents radionecrosis DISEASE . The patient had midline
shift and mass effect. On [**2118-8-10**] she had a left craniotomy for
resection of the radionecrosis DISEASE . She then presented to the office
in [**2118-8-27**] with increased left facial swelling DISEASE and incision
drainage she was taken to the OR for a wound washout and
craniectomy. She now returns for a cranioplasty after a long
course of outpatient IV antibiotic therapy.


Past Medical History:
seizuresh/o radio therapy for avm has resid edema DISEASE causing
seizuresAdmission Date: [**2176-7-30**] Discharge Date: [**2176-8-4**]

Date of Birth: [**2114-2-8**] Sex: M

Service: [**Hospital1 212**]

HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old
male with a past medical history of squamous cell lung cancer DISEASE
treated with right total pneumonectomy chronic obstructive
pulmonary disease DISEASE on 2 to 3 liters of home oxygen with
saturations in the low 90s at baseline congestive heart
failure DISEASE and diabetes mellitus DISEASE type 2 who was recently
admitted from [**7-15**] to [**2176-7-19**] for presumed
bronchitis DISEASE or bronchiectasis DISEASE flare here with recurrent cough DISEASE
shortness of breath DISEASE and fevers DISEASE . During his last admission
two weeks ago he was treated for chronic obstructive pulmonary disease DISEASE flare versus bronchitis DISEASE with a ten day
Prednisone taper and Augmentin for one week. He underwent
bronchoscopy due to concern for possible endobronchial
lesion which was normal. Sputum sample was done at that
time showed no growth. He was discharged at his baseline
function on [**2176-7-19**]. The plan was to treat him for one
week of Augmentin skip one week followed by Bactrim for one
week skip one week and then on Augmentin for two weeks for
pneumonia DISEASE prophylaxis. The last dose of Augmentin was
[**2176-7-22**] after being on Augmentin for only three days.

He was doing well until approximately one week ago when he
developed mild spasms DISEASE in the afternoon that he thought was
due to low potassium. Within the following days he
complained of worsening cough DISEASE productive of clear sputum. He
had a low grade temperature mild headache DISEASE and worsening
cough DISEASE and presented to the Emergency Department. He denied
any sinus pain sore throat chest pain abdominal pain DISEASE
diarrhea dysuria DISEASE or joint pain DISEASE . In the Emergency Department
he was febrile to 102 orally and had a heart rate of 160 and
a blood pressure of 118/56. Respiratory rate 28. Sating 88
to 98% on 100% nonrebreather. Initially he was stable but
then had a gradual change in mental status with hypoxia DISEASE
which resulted in his elective intubation. He received Lasix
100 mg intravenous twice 1 mg of Bumex and 1 gram of
Ceftriaxone as well as 125 mg of Solu-Medrol. He was also
placed on a heparin drip for a subtherapeutic INR and given
morphine and Ativan for sedation. Chest x-ray showed no
focal pneumonia DISEASE or evidence of heart failure DISEASE . The patient
then underwent a CT angiogram of the chest that showed no
evidence of pulmonary embolism DISEASE .

PAST MEDICAL HISTORY: 1. Stage three squamous cell lung DISEASE
cancer DISEASE diagnosed in [**2175-2-26**] status post right
pneumonectomy in [**2175-6-28**] treated with neoadjuvant
radiation therapy and carboplatin and Taxol. 2. Chronic
obstructive pulmonary disease DISEASE . 3. Congestive heart failure
last echocardiogram [**2176-6-18**] with limited views showing
grossly preserved left ventricular function and right
ventricular function. 4. Atrial fibrillation DISEASE in the
postoperative period. 5. History of prostate cancer DISEASE
diagnosed in [**2172-2-26**] status post radical proctectomy
with penile DISEASE prosthesis in [**2172-8-27**]. 6. Diabetes
mellitus DISEASE type 2. 7. History of urosepsis DISEASE . 8. History of
pulmonary embolus DISEASE postoperative in [**2175-6-28**]. 9.
Myocardial infarction DISEASE with a troponin of 4.1 in [**2175-6-28**]. Cardiac catheterization showed 30% right coronary
lesion normal left ventricular function with an ejection
fraction of 50%. 10. Transient ischemic attack in [**2165**].
11. Gout. 12. Gastroesophageal reflux disease DISEASE . 13. Sleep
apnea DISEASE . 14. Colonic polyps discovered in [**2173-5-27**]. 15.
Hypercholesterolemia DISEASE . 16. Small pericardial effusion DISEASE in
[**2176-5-27**] which subsequently resolved.

ALLERGIES: Doxepin causes delirium DISEASE and Levaquin causes
prolonged QTs.

MEDICATIONS ON ADMISSION: Bactrim 800 mg/160 one tablet
twice a day for one week skip one week and then Augmentin 500
mg three times a day. Potassium 40 milliequivalents twice a
day. Protonix 40 mg once daily. Lasix 160 mg b.i.d.
Uniphyl 200 mg q.d. Zestril 2.5 mg q.d. Serevent two puffs
b.i.d. Flovent 110 micrograms four puffs twice a day.
Combivent inhaler two puffs four times a day. Duo-neb
solution four times a day as needed. Amiodarone 200 mg q.d.
enteric coated aspirin 325 mg a day Glyburide 5 mg once a
day Colace 100 mg twice a day Senna prn Coumadin 5 mg once
a day except for 4 mg on Tuesday and Thursday Neurontin 300
mg b.i.d. Oxycontin 20 mg t.i.d. Paxil 20 mg q.d. Lipitor
10 mg q.d. Ambien 15 mg q.h.s. and a regular insulin sliding
scale.

SOCIAL HISTORY: The patient quit smoking in [**2175-5-28**]
following a forty year history of smoking three to four packs
a day. He consumed two to three drinks alcoholic drinks per
day and was a construction worker.

FAMILY HISTORY: The patient has a sister who died of cancer DISEASE
at the age of 39 and an older brother who had a coronary
artery bypass graft. His father also had coronary artery
disease and he had a sister with cardiac valvular disease DISEASE .

PHYSICAL EXAMINATION: This was a gentleman who was
intubated sedated and responsive only to noxious stimuli.
Pupils were unremarkable. There were no bruits DISEASE in the neck.
Heart had a regular rate and rhythm with normal S1 and S2
sounds faint heart sounds overall. Occasional ectopic
beats. Lungs were clear to auscultation on the left with
transmitted breath sounds on the right. Abdomen was soft and
mildly distended with decreased bowel sounds DISEASE . Extremities
showed no evidence of ulcers trace edema DISEASE in both lower
extremities and no cyanosis DISEASE or clubbing DISEASE . Skin showed no
evidence of rashes DISEASE .

LABORATORY EXAMINATION: Urinalysis was unremarkable. White
blood cell count 23 hematocrit 42 platelets were 297.

HOSPITAL COURSE: Upon admission to the hospital the patient
was transferred to the Medical Intensive Care Unit where he
was treated for presumed bronchitis DISEASE versus tracheobronchitis DISEASE
versus atypical pneumonia DISEASE . Blood sputum urine and stool
cultures were sent and Ceftriaxone and Azithromycin were
started.

1. Infectious disease: The patient did not develop a focal
infiltration throughout his hospitalization. His Ceftriaxone
was stopped and he was continued on Azithromycin. He
remained afebrile throughout the rest of his hospital stay
and his white blood cell count decreased daily. On hospital
day two he was stable for extubation and tolerated extubation
very well. He was then transferred on hospital day number
three out of the Intensive Care Unit to the medical floor.
He continued to improve clinically with a decrease in his
fever DISEASE curve and decrease in his oxygen requirements. He also
subjectively improved and on his last hospital day he was
comfortable and ambulating without oxygen. He stated that he
had come back to his baseline. White blood cell count
returned to [**Location 213**] range and cultures were negative except
for one anaerobic bottle that was growing gram positive
coxae that had been unidentified by the time of discharge.

2. Pulmonary: This was treated as possible
tracheobronchitis DISEASE versus chronic obstructive pulmonary DISEASE
disease versus atypical pneumonia DISEASE . The patient was kept on
his usual inhaler and nebulizing medications as well as
Azithromycin and intravenous Solu-Medrol. After hospital day
number two and the patient was extubated and improving the
Solu-Medrol was switched to Prednisone and was rapidly
tapered. The patient was encouraged to ambulate and was
given regular respiratory treatment and chest physical
therapy. By the end of the hospitalization the patient felt
that he had returned to his baseline lung function baseline
pulmonary function and was coughing up less dark sputum. To
manage his congestive heart failure DISEASE Lasix was used
judiciously in order to gently diurese him over the course of
the hospitalization followed by urine output and daily
weights. The patient responded to this well and felt overall
that his symptoms of volume overload DISEASE had improved.

3. Cardiovascular: Based on his presentation it was not
clear that there was not a cardiac component causing his
change in his status so cardiac enzymes were sent. Three
sets of enzymes were negative and showed no evidence of
myocardial infarction DISEASE . He had a number of electrocardiograms
that were checked to ensure that he did not have a
significantly prolonged QTC interval and that it was not
worse.

4. Endocrine: The patient was followed with blood glucose
measurements that showed that his glucose was under poor
control with the Glyburide and the regular insulin sliding
scale. As the regular insulin sliding scale was increased
and the Prednisone was tapered these values returned closer
to normal.

CONDITION ON DISCHARGE: Improved.

DISCHARGE STATUS: To home.

DISCHARGE MEDICATIONS: 1. Humibid LA 600 mg b.i.d. 2.
Lasix 160 mg b.i.d. 3. Potassium 40 milliequivalents po
b.i.d. 4. Uniphyll 200 mg q.d. 5. Protonix 40 mg q.d. 6.
Zestril 2.5 mg q.d. 7. Serevent two puffs b.i.d. 8.
Flovent 110 micrograms four puffs b.i.d. 9. Combivent two
puffs q.i.d. 10. Scopolamine patch q 72 hours. 11.
Albuterol nebulizer q 6 hours prn. 12. Amiodarone 200 mg po
q.d. 13. Enteric coated aspirin 325 mg q.d. 14. Glyburide
5 mg q.a.m. 15. Regular insulin sliding scale as per
previously. 16. Colace 100 mg po b.i.d. 17. Senna two
tabs po b.i.d. 18. Coumadin on hold until [**8-5**]. 19.
Prednisone taper over eight days. 20. Augmentin 500 mg
t.i.d. 21. Lipitor 10 mg q.d. 22. Neurontin 300 mg po
b.i.d. 23. Oxycodone 20 mg q 8 hours prn. 24. Paxil 20 mg
po q.d. 25. Ambien 10 to 15 mg po q.h.s. prn.

The patient had been using Care Group Respiratory Services at
home for pulmonary physical therapy and O2 assistance and so
this was arranged on an outpatient basis with chest physical
therapy and incentive spirometry and other pulmonary
treatments. The plan was that he would follow up with Dr.
[**Last Name (STitle) **] in clinic the following week and that he would have
an INR drawn on [**8-6**] calling the results to Dr. [**Last Name (STitle) **].

DISCHARGE DIAGNOSES:
1. Bronchitis.
2. Possible atypical pneumonia DISEASE .







[**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**] M.D. [**MD Number(1) 200**]

Dictated By:[**Last Name (NamePattern1) 214**]

MEDQUIST36

D: [**2176-8-4**] 15:11
T: [**2176-8-12**] 06:15
JOB#: [**Job Number 215**]
Admission Date: [**2145-6-27**] Discharge Date: [**2145-7-2**]


Service: [**Location (un) 259**]

HISTORY OF PRESENT ILLNESS: On admission the patient is an
86[**Hospital 4622**] nursing home resident who reports recent fevers DISEASE
and coughs productive of white sputum as well as right sided
chest pain DISEASE . She developed dyspnea DISEASE saying that her breathing
is all right. She denied chest pain DISEASE and abdominal pain DISEASE . At
her nursing home she was diagnosed with pneumonia DISEASE was given
Zithromax on [**6-26**] initially 500 per day then 250 mg
thereafter. Yesterday she continued to spike fevers DISEASE . She
was given ceftriaxone 1 gm. Her fevers DISEASE curtailed throughout
the day. Her blood pressure was recorded to be 84/40 and was
transferred to [**Hospital6 256**] for
further evaluation. At [**Hospital3 **] she was given fluid to
support her blood pressure. Her cultures were drawn and was
given levofloxacin and Flagyl for presumed pneumonia DISEASE . The
Medical Intensive Care Unit was called to evaluate the
patient for low blood pressure and after 4 liters of fluid
her blood pressures did not significantly improve.

PAST MEDICAL HISTORY:
1. Severe rheumatoid arthritis DISEASE
2. Lower gastrointestinal bleed DISEASE from gastritis DISEASE in '[**36**]
3. Decubiti ulcers DISEASE
4. Congestive heart failure DISEASE

MEDICATIONS:
1. Zithromax 250 mg
2. Albuterol nebulizers q6
3. Robitussin 10 cc qid for five days
4. Ceftriaxone 1 gm multivitamin qd
5. Lasix 2 mg po qd
6. Iron 325 mg po qd
7. Prevacid 50 mg [**Hospital1 **]
8. Tylenol 650 mg po tid
9. Capoten 6.25 mg po tid

ALLERGIES: She is not allergic DISEASE to any medication.

SOCIAL HISTORY: She is a nursing home resident. She quit
smoking 60 years ago.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: As above.

PHYSICAL EXAM DISEASE :
VITAL SIGNS: On admission her temperature was 101.8Admission Date: [**2180-6-12**] Discharge Date: [**2180-7-5**]


Service: VASCULAR SURGERY

CHIEF COMPLAINT: Ischemic right fifth toe ulcer DISEASE .

HISTORY OF PRESENT ILLNESS: This is a 79-year-old white
female with coronary artery disease DISEASE status post myocardial
infarction DISEASE with coronary artery bypass grafting in [**2170**]
myocardial infarction DISEASE with congestive heart failure DISEASE in
[**2179-11-9**] with diabetes end-stage renal disease DISEASE on
hemodialysis status post left above-knee amputation in [**2175**]
who complained of an eight-month history of right forefoot
ulceration. In spite of treatment the patient's left fifth
toe ulceration has not healed.

Over the previous week prior to admission the patient noted
changes in the color of her right toes. She denied rest
pain DISEASE . She complained of prior symptoms of right lower
extremity claudication DISEASE although currently she is wheelchair
bound. She has a left lower extremity prosthesis which she
does not use.

The patient was seen in the office a week prior to admission
and scheduled for admission and elective revascularization of
her right leg.

PAST MEDICAL HISTORY:
1. Coronary artery diseaseAdmission Date: [**2135-1-31**] Discharge Date: [**2135-2-3**]

Date of Birth: [**2065-8-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Respiratory distress DISEASE .

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
69yoF with T8 paraplegia DISEASE who presented to the ED with 6 days of
Admission Date: [**2135-12-12**] Discharge Date: [**2135-12-14**]

Date of Birth: [**2065-8-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Mental status change

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
HPI: Ms. [**Known lastname 4636**] is a 70 yo female with h/o paraplegia HTN DISEASE
and Admission Date: [**2136-9-11**] Discharge Date: [**2136-9-15**]

Date of Birth: [**2065-8-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Adhesive Tape

Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Mental status change abdominal pain DISEASE

Major Surgical or Invasive Procedure:
Flexible Sigmoidoscopy
Right IJ intravenous catheter placement


History of Present Illness:
Ms. [**Known lastname 4636**] is a 71 yo wheel-chair bound woman with
paraplegia hypertension DISEASE and question of COPD DISEASE who was admitted
on [**9-11**] with altered mental status. Per the patient she had
been experiencing constipation DISEASE for 5-6 days prior to admission.
She did have a small BM on the morning of admission. On the day
of admission the patient reported feeling sweaty and dizzy and
dropped a cup of tea onto her lap. Her neighbor who was
visiting noticed she was weak and dysarthric and called
lifeline who then brought the patient to the ED.
.
In the ED her initial vitals were temp 99.5 bp 113/44 HR 96
RR 16 SaO2 96% on NRB DISEASE . Her bp decreased to 81/38 DISEASE in the ED and
she became unable to respond to commands so she was given 4 L
NS. Her bp slightly improved to 91/45 DISEASE . She also had a large
loose BM in ED. A right IJ was placed. UA was nitrite positive
with moderate bacteria. CXR was concerning for left lower lobe
pneumonia DISEASE . The patient was thought to have sepsis DISEASE [**1-6**] to PNA
vs. UTI DISEASE and she was given Vancomycin 1 mg IV x1 Levaquin 750
mg IV x1 and Tylenol PR 1 gm x1 and transferred to the MICU.
.
In the MICU the patient was started on Levophed for pressure
support. WBC 19.6 with a left shift Lactate 3.4 -Admission Date: [**2137-7-2**] Discharge Date: [**2137-7-9**]

Date of Birth: [**2065-8-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Adhesive Tape

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Hypotension DISEASE

Major Surgical or Invasive Procedure:
RIJ placement

History of Present Illness:
Ms. [**Known lastname 4636**] is a 71yo paraplegic female with PMH significant
for HTN DISEASE HLD and chronic UTI's who is being transferred to the
MICU for management of hypotension DISEASE . Per her son
the patient's home nurse noted that she had a slight temperature
this morning. Her son noted that her appetite was poor and was
also incoherent. He also noted that her catheter contained urine
that was dark and concentrated. He immediately called 911. She
was then brought to [**Hospital1 18**] ED for further work-up. There is no
report of SOB chest pain abdominal pain diarrhea DISEASE or
constipation DISEASE . The son was also concerned that her catheter was
not working well and needed to be changed.
In the ED initial vitals were T 102.2 BP 115/33 AR 105 RR 18 O2 sat 94% on 3L NC. She received Vancomycin 1gm IV Zosyn 4.5gm
IV and Tylenol 1gm. Her blood pressure dropped to 95/43 and
given lack of improvement after receiving 3L NS she is being
transferred to the MICU for closer monitoring.

Past Medical History:
1)Paraplegia [**1-5**] Anterior Spinal Infarct DISEASE
2)Thoracic Aneurysm DISEASE Repair ([**2128**])
3)Hx of LLL Collapse/PNA s/p mucous plug removal via
bronchoscopy
4)HTN
5)Hyperlipidemia DISEASE
6)GERD
7)Suprapubic Catheter Placement / UTIs DISEASE on Ppx Bactrim
8)Fecal Incontinence
9)Depression

Social History:
58 year tobacco history now smoking 3 cigarettes per day
denies EthOH denies drug abuse DISEASE . Widowed. Has 3 sons. She
lives alone in [**Hospital3 4634**].

Family History:
Son has DM

Physical Exam:
vitals T 95.8 BP 117/50 AR 65 RR 23 O2 sat 95% on 3L NC
Gen: Patient awake responsive to commands
HEENT: MMM PERRLA
Heart: RRR no audible mrg
Lungs: CTAB scattered crackles at posterior bases
Abdomen: Markedly distended but soft NT Admission Date: [**2137-11-6**] Discharge Date: [**2137-11-20**]

Date of Birth: [**2065-8-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Adhesive Tape

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Altered mental status hypotension hypoxia DISEASE .


Major Surgical or Invasive Procedure:
CT-guided drainage of left gluteal abscess ([**2137-11-15**]).


History of Present Illness:
Mrs. [**Known lastname 4636**] is a 72 y/o woman with PMH notable for paraplegia DISEASE
[**1-5**] anterior spinal artery infarct indwelling suprapubic
catheter with frequent UTIs DISEASE admitted with altered mental status
and hypoxia DISEASE . Per nursing facility notes the patient was noted
to be unresponsive to voice commands but responsive to tactile
stimuli. Vitals at the time were BP 100/50 HR 100 RR 20 O2
80% on RA DISEASE which increased to 97% on 6 L NC. Reportedly she is
alert & oriented X 3 at her baseline. Of note she is currently
on nitrofurantoin 100 mg PO BID for a UTI DISEASE (Admission Date: [**2138-10-15**] Discharge Date: [**2138-10-23**]

Date of Birth: [**2065-8-18**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Adhesive Tape

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fever DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
73F with paraplegia DISEASE recurrent UTI DISEASE chronic sacral decubs
presenting with fever DISEASE and altered mental status. She was seen by
her NP yesterday with fever DISEASE to 102 and positive UA. Her sacral
decub was noted to be improved since last exam. Cipro started
for UTI DISEASE . Also seen by her visiting nurse today and son reported
that overnight she was confused talking about getting up to
walk (though paraplegic) and Admission Date: [**2196-3-5**] Discharge Date: [**2196-4-20**]

Date of Birth: [**2127-1-18**] Sex: M

Service: [**Last Name (un) **]


CHIEF COMPLAINT: Fevers chills abdominal pain DISEASE in the right
upper quadrant worsening shortness of breath x1 day
pleuritic like chest pain DISEASE and nausea DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male with a history of polycystic kidney disease DISEASE status post
cadaveric renal transplant in [**2190**] on Rapamune prednisone
and Gengraf. The patient has a history of polycystic liver DISEASE
disease with recent cyst infections DISEASE treated with IV
antibiotics recently presents with 2 week history of fevers DISEASE
up to 101 chills malaise DISEASE and shortness of breath DISEASE with
increasing abdominal distention DISEASE and right upper quadrant
pain DISEASE . The patient saw Dr. [**First Name (STitle) **] in the clinic the week
prior and was instructed to go to the hospital for further
evaluation. The patient felt worse however and came to the
emergency department for evaluation and workup. The patient
complained of malaise and shortness of breath DISEASE but denied
chest pain DISEASE . He denied any anorexia DISEASE or urinary symptoms or new
bowel changes. He did complain of nausea DISEASE and some dry heaves DISEASE .
The patient has a history of polycystic kidney disease DISEASE with
also polycystic liver disease DISEASE with multiple large liver
cysts one of which became infected secondarily with a
pansensitive pseudomonas following episode of ERCP induced
cholangitis DISEASE and bacteremia DISEASE in [**2195-8-20**]. At that time
he was initially treated with PIP/TAZO followed by
recurrence of fevers DISEASE and persistence of the abscess. He was
drained in [**2195-10-20**] and treated with 6 weeks of Cipro
plus 2 weeks of Augmentin for an unidentified gram positive
cocci through late [**Month (only) 404**]. He did well through [**2196-2-17**]
when he had recurrent low fevers DISEASE and malaise. Repeat MRI
showed enlargement of the left lateral liver abscess DISEASE that was
impinging on the diaphragm and pericardium. He was started on
oral Cipro as an outpatient. He continued to have low grade
fevers DISEASE .

ALLERGIES: No known drug allergies DISEASE .

PAST MEDICAL HISTORY: Polycystic kidney disease DISEASE
hypertension GERD endstage renal disease DISEASE status post
cadaveric renal transplant in [**2190**] CHF biliary stones DISEASE
diverticulosis DISEASE chronic pancreatitis cholestasis DISEASE .

PAST SURGICAL HISTORY: Cadaveric renal transplant in [**2190**]
biliary stenting and an AV fistula DISEASE .

MEDICATIONS: At home prednisone 5 mg Lopressor 75 mg p.o.
b.i.d. cyclosporin 25 mg b.i.d. doxazosin Rapamune 1 mg
p.o. daily Protonix allopurinol 50 mg p.o. b.i.d. Lasix 20
mg p.o. daily and Bactrim single strength daily.

The patient was admitted to the transplant service. Full labs
were sent off. A KUB and chest x-ray were done that
demonstrated massive cardiomegaly DISEASE and pericardial effusion DISEASE .
Blood cultures and urine cultures were sent. These were
subsequently negative.

PHYSICAL EXAMINATION: On admission temperature was 99.7
heart rate 89 blood pressure 133/68 respiratory rate 24 O2 saturation 96% in room air. He was mildly uncomfortable
appeared uncomfortable. No scleral icterus. EOMI. Respiratory
rate regular. Lungs were decreased on the left base with end
expiratory crackles at base. He was tachypneic especially
when supine. Heart: Regular rate and rhythm no murmurs but
distant sounds. Abdomen moderately distended tender over
right upper quadrant. He was tympanitic no rebound no
guarding. Extremities: Warm no clubbing cyanosis DISEASE 1Unit No: [**Numeric Identifier 4666**]
Admission Date: [**2196-6-29**]
Discharge Date: [**2196-7-24**]
Date of Birth: [**2127-1-18**]
Sex: M
Service:


Per dictator: Admission Date: [**2176-8-17**] Discharge Date: [**2176-8-21**]

Date of Birth: [**2114-2-8**] Sex: M

Service:

CHIEF COMPLAINT: Respiratory distress.

HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
male with a past medical history significant for lung cancer DISEASE
status post right pneumonectomy in [**2175-6-28**] six
hospitalizations since [**2176-5-27**] last discharged on
[**2176-8-4**] with the diagnosis of tracheal bronchitis DISEASE
versus chronic obstructive pulmonary disease DISEASE flare versus
atypical pneumonia DISEASE status post intubation in the MICU
chronic secretions/congestion-related problems on
alternating regimen of Augmentin and Bactrim since [**2175-9-28**] for multiple bronchitic-like infections DISEASE chronic
obstructive pulmonary disease congestive heart failure DISEASE
atrial fibrillation DISEASE prior PEs diabetes type 2 status post
myocardial infarction DISEASE who presented with gradual shortness
of breath beginning on the day of admission.

The patient reported a [**1-29**] day history of general fatigue DISEASE .
On the day of admission visiting nurse services reported a
systolic blood pressure of 70. The wife drove the patient to
the Emergency Room. The patient also complained of some
dizziness DISEASE however denied other symptoms including fever DISEASE
chills sweats chest pain diarrhea constipation nausea DISEASE
vomiting DISEASE or urinary symptoms. He reported good p.o. intake
and appetite.

The patient reported that he has a chronic slight cough DISEASE
however denied any sputum production. He took his oral
temperature at home and denied any fever DISEASE . At home the
patient is on oxygen of [**12-31**] L via nasal cannula. The patient
recently finished a steroid taper on [**8-14**] which was
two weeks in length. He reported a usual SBP of 80-110. The
patient did note that since [**Month (only) 216**] a Scopolamine patch was
added to his regimen and has increased his secretions
significantly.

EMERGENCY DEPARTMENT COURSE: Per Emergency Room the patient
appeared close to intubation upon presentation and was placed
on 100% oxygen via non-rebreather with an ABG of 7.46 pCO2
of 48 and pO2 of 33. There was a question if this was a
venous gas or not. Lasix 100 mg IV Albuterol nebs
Solu-Medrol 600 mg IV and Ceftriaxone 1 g IV was given to
the patient. When evaluated by the MICU shortly after
arrival to the Emergency Room the patient was weaned down to
baseline of 2 L oxygen with oxygen saturation of 100% via
nasal cannula. The patient was breathing comfortably at
18-20 breaths/min. The patient no longer complained of
shortness of breath DISEASE but did state that he felt slightly
tired. Chest x-ray was negative and a CT showed no acute
PE. The patient reported that he was back to baseline in the
Emergency Room.

PAST MEDICAL HISTORY: 1. Stage III squamous cell lung DISEASE
cancer DISEASE diagnosis in [**2175-2-26**] status post right
pneumonectomy in [**2175-6-28**] with radiation Carboplatin
and Taxol treatments. 2. Chronic obstructive pulmonary
disease with PFTs in [**2176-5-27**] showing an FEV1 of 0.83 L
which is 25% of predicted and FEV1 to FVC ration of 68% of
predicted. 3. Congestive heart failure DISEASE with preserved left
ventricular function in [**2176-5-27**]. 4. Atrial fibrillation DISEASE .
This was noted perioperatively. 5. Prostate carcinoma DISEASE
diagnosed in [**2172-2-26**] status post radical prostatectomy in
[**2172-8-27**]. 6. Diabetes type 2. 7. History of
urosepsis DISEASE . 8. History of PE during the patient's
postoperative course in [**2175-6-28**]. 9. Status post
myocardial infarction DISEASE . This was also perioperative in [**2175-6-28**]. Catheterization at that time showed normal left
ventricular function ejection fraction of 50% and a 30%
right coronary artery lesion DISEASE . 10. Status post transient
ischemic attack in [**2165**]. 11. Gout. 12. Gastroesophageal
reflux disease DISEASE . 13. Sleep apnea. 14. Colonic polyps noted
in [**2173-5-27**]. 15. Hypercholesterolemia DISEASE .

ALLERGIES: Doxepin causes delirium DISEASE . Levaquin causes
prolonged QTCs. OxyContin causes Unit No: [**Numeric Identifier 4669**]
Admission Date: [**2167-8-11**]
Discharge Date: [**2167-8-15**]
Date of Birth: [**2091-6-8**]
Sex: M
Service:


HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 76-year-old man
with a history of hypertension dyslipidemia DISEASE and coronary
artery disease DISEASE (status post inferior myocardial infarction DISEASE
with ventricular fibrillation arrest DISEASE in [**2156**]) who has done
well with only six episodes of exertional angina DISEASE until then.

Three days ago the patient woke up at 3:00 a.m. with severe
midsternal chest pain DISEASE radiating to the left arm. It was
similar to the symptoms of his prior myocardial infarction DISEASE .
It was not associated with nausea vomiting diarrhea DISEASE or
shortness of breath DISEASE .

The patient presented to [**Hospital **] Hospital within one half
hour of the onset of the pain DISEASE where he was treated with
sublingual nitroglycerin oxygen morphine and heparin. The
patient became pain DISEASE free and remained so for the remainder of
his hospitalization. The patient ruled in for a myocardial
infarction DISEASE with a positive troponin level of 2.87 and a
creatine kinase of 426.

Cardiac catheterization performed on the day prior to
admission at [**Hospital **] Hospital demonstrated a small LIMA
total occlusion of the SVG to OM and diseased segments of
the SVG to diagonal to obtuse marginal. The ejection
fraction was normal. The LV end-diastolic pressure was 19
right atrial pressure was 13 and pulmonary artery pressure
33/10.

The patient was transported to [**Hospital1 188**] on the day of admission where he underwent stenting of
the saphenous vein graft to diagonal and obtuse marginal with
a PercuSurge distal protection device. The patient
experienced his typical anginal symptoms DISEASE during the procedure
and for approximately one hour status post procedure.

The patient denied a history of shortness of breath dyspnea DISEASE
on exertion paroxysmal nocturnal dyspnea orthopnea DISEASE
palpitations lightheadedness syncope DISEASE or presyncope DISEASE .

PAST MEDICAL HISTORY:
1. Coronary artery diseaseAdmission Date: [**2118-9-22**] Discharge Date: [**2118-10-9**]

Date of Birth: [**2042-5-18**] Sex: M

Service:

CHIEF COMPLAINT: Expanding infrarenal abdominal DISEASE aortic
aneurysm DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
male with a known 6.5 x 5.5 cm infrarenal abdominal aortic
aneurysm DISEASE who presented to the emergency department after
experiencing weakness DISEASE and diaphoresis DISEASE while at his dentist's
office. He was also complaining of severe bilateral lower
extremity claudication and back pain DISEASE for two weeks. He took
nitroglycerin at the dentist's office with some relief and
was sent to the emergency department for evaluation.

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post myocardial
infarctions DISEASE in [**2091**] [**2079**] and [**2059**].
2. Cerebrovascular accident.
3. Chronic obstructive pulmonary disease DISEASE .
4. Hypertension.
5. Peripheral vascular disease DISEASE .
6. Infrarenal abdominal aortic aneurysm DISEASE 6.5 x 5.5 cm.

ALLERGIES: None known.

MEDICATIONS ON ADMISSION:
1. Toprol 300 mg qd
2. Lipitor 10 mg qd
3. Imdur 120 mg qd
4. Vioxx 25 mg qd
5. Norvasc 25 mg qd
6. Pepcid 20 mg qd
7. Singulair 10 mg
8. .............. 100 mg b.i.d.
9. Lasix 20 mg qd
10. Allopurinol 100 mg qd
11. .............. 60 mg qd
12. Trental 400 mg t.i.d.
13. Zoloft 25 mg qd
14. Antivert 12.5 mg qd
15. Flovent 10 mg

PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 138/88
heart rate 72 and irregular 98% on two liters. General
Exam: Obese male. HEENT: EOMI. MMM. Cardiovascular:
Irregular heart rate. Lungs: Clear to auscultation
bilaterally. Abdomen: Obese soft tender. Pulsatile mass.
Rectal: Guaiac negative normal tone. Extremities:
Palpable radials left femoral left popliteal left dorsalis
pedis left posterior tibial palpable.

LABS ON ADMISSION: Chemistries showed sodium 144 potassium
4.6 chloride 108 bicarbonate 22 BUN 31 creatinine 1.9
glucose 121. CBC showed hematocrit 44.5 white cell count
11.3 platelets 175000. Coagulations: PT 13.1 PTT 6.1
INR 1.1

Electrocardiogram on admission showed atrial fibrillation DISEASE .

HOSPITAL COURSE: The patient was diagnosed as having an
expanding infrarenal abdominal aortic aneurysm DISEASE and was
admitted to the Vascular Intensive Care Unit VICU for
monitoring and preparation for surgery on the following day.
A Cardiology consult was obtained and they recommended
short-acting beta blocker therapy.

On [**2118-9-23**] he underwent an abdominal aortic aneurysm DISEASE
resection with oversewing of the left CIA ligation of right
CIA DISEASE aortobifemoral with profunda bypass with bifurcated
Dacron graft. Postoperatively he remained intubated for
hemodynamic monitoring and was transferred to the PACU and
started on Lopressor drip.

On postoperative day #1 he was extubated and transferred to
the Surgical Intensive Care Unit for further monitoring. On
postoperative day #1 his urine output was low and he was
diagnosed as having ATN DISEASE and seemed to be fluid overloaded.
He responded to Lasix. It was also noted that his cardiac
enzymes were elevated and he was ruled in with a non-Q wave
MI. He was then started on Cardiology recommendations on
aspirin and continued beta blockade.

He was relatively stable over the next couple of days
although he was requiring blood transfusions on a frequent
basis. Postoperative echocardiogram on [**2118-9-26**] revealed an
EF of less than 25% (preoperatively about 35%) and global
hypokinesis of the left ventricle mild pulmonary
hypertension DISEASE 1Admission Date: [**2118-9-22**] Discharge Date: [**2118-10-9**]

Date of Birth: [**2042-5-18**] Sex: M

Service:

CHIEF COMPLAINT: Expanding infrarenal abdominal DISEASE aortic
aneurysm DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
male with a known 6.5 x 5.5 cm infrarenal abdominal aortic
aneurysm DISEASE who presented to the emergency department after
experiencing weakness DISEASE and diaphoresis DISEASE while at his dentist's
office. He was also complaining of severe bilateral lower
extremity claudication and back pain DISEASE for two weeks. He took
nitroglycerin at the dentist's office with some relief and
was sent to the emergency department for evaluation.

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post myocardial
infarctions DISEASE in [**2091**] [**2079**] and [**2059**].
2. Cerebrovascular accident.
3. Chronic obstructive pulmonary disease DISEASE .
4. Hypertension.
5. Peripheral vascular disease DISEASE .
6. Infrarenal abdominal aortic aneurysm DISEASE 6.5 x 5.5 cm.

ALLERGIES: None known.

MEDICATIONS ON ADMISSION:
1. Toprol 300 mg qd
2. Lipitor 10 mg qd
3. Imdur 120 mg qd
4. Vioxx 25 mg qd
5. Norvasc 25 mg qd
6. Pepcid 20 mg qd
7. Singulair 10 mg
8. .............. 100 mg b.i.d.
9. Lasix 20 mg qd
10. Allopurinol 100 mg qd
11. .............. 60 mg qd
12. Trental 400 mg t.i.d.
13. Zoloft 25 mg qd
14. Antivert 12.5 mg qd
15. Flovent 10 mg

PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 138/88
heart rate 72 and irregular 98% on two liters. General
Exam: Obese male. HEENT: EOMI. MMM. Cardiovascular:
Irregular heart rate. Lungs: Clear to auscultation
bilaterally. Abdomen: Obese soft tender. Pulsatile mass.
Rectal: Guaiac negative normal tone. Extremities:
Palpable radials left femoral left popliteal left dorsalis
pedis left posterior tibial palpable.

LABS ON ADMISSION: Chemistries showed sodium 144 potassium
4.6 chloride 108 bicarbonate 22 BUN 31 creatinine 1.9
glucose 121. CBC showed hematocrit 44.5 white cell count
11.3 platelets 175000. Coagulations: PT 13.1 PTT 6.1
INR 1.1

Electrocardiogram on admission showed atrial fibrillation DISEASE .

HOSPITAL COURSE: The patient was diagnosed as having an
expanding infrarenal abdominal aortic aneurysm DISEASE and was
admitted to the Vascular Intensive Care Unit VICU for
monitoring and preparation for surgery on the following day.
A Cardiology consult was obtained and they recommended
short-acting beta blocker therapy.

On [**2118-9-23**] he underwent an abdominal aortic aneurysm DISEASE
resection with oversewing of the left CIA ligation of right
CIA DISEASE aortobifemoral with profunda bypass with bifurcated
Dacron graft. Postoperatively he remained intubated for
hemodynamic monitoring and was transferred to the PACU and
started on Lopressor drip.

On postoperative day #1 he was extubated and transferred to
the Surgical Intensive Care Unit for further monitoring. On
postoperative day #1 his urine output was low and he was
diagnosed as having ATN DISEASE and seemed to be fluid overloaded.
He responded to Lasix. It was also noted that his cardiac
enzymes were elevated and he was ruled in with a non-Q wave
MI. He was then started on Cardiology recommendations on
aspirin and continued beta blockade.

He was relatively stable over the next couple of days
although he was requiring blood transfusions on a frequent
basis. Postoperative echocardiogram on [**2118-9-26**] revealed an
EF of less than 25% (preoperatively about 35%) and global
hypokinesis of the left ventricle mild pulmonary
hypertension DISEASE 1Admission Date: [**2105-9-8**] Discharge Date: [**2105-9-16**]

Date of Birth: [**2053-8-14**] Sex: M

Service: NEUROSURGERY

Allergies DISEASE :
seasonal

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
neck and bilateral arm pain DISEASE

Major Surgical or Invasive Procedure:
[**2105-9-8**]: Anterior cervical removal of hardware and loose
screws
[**2105-9-8**]: Neck exploration Repair of pharynx direct
laryngoscopy


History of Present Illness:
Patient comes in today for discussion of surgery - revision of
cervical fusion that is scheduled for this week. Patient states
he has pain DISEASE in his neck to 2 inches below his elbow bilateral.
He states that the pain DISEASE in his neck is sharp shooting in nature
and the arms are a constant dull ache DISEASE . Left side is worse and he
feels his neck cracking. He was initially seen
[**2105-5-21**]. He also notes difficulty swallowing

CT reviewed at that visit. Per Dr.[**Name (NI) 4674**] note: Prior
surgery with a plate lying anterior at the C4 through C6 levels.
The screws at C5 are slightly inferior placed. There is probably
nonunion at C4-C5. There are two completely extruded screws
inferior to that plate probably coming from the C4 and C5 areas.
They are in close contact with the esophagus and potentially
causing the symptoms of dysphagia DISEASE .
The risks and benefits of undergoing surgical intervention were
discussed with the patient. He now electively presents for ACDF
revision.

Past Medical History:
1. Recurrent syncope DISEASE of unclear etiology with no arrhythmia DISEASE
identified on extended monitoring with a Reveal implanted
monitor
2. Single brief episode of atrial fibrillation DISEASE
3. Hypertension DISEASE
4. Hyperlipidemia DISEASE
5. Obesity DISEASE
6. COPD DISEASE (PFT's [**2-/2105**]: moderately severe obstructive defect DISEASE with
significant improvement in bronchodilator mild reduction in
diffusing capacity)
7. Prior failed cervical fusion (C3-C5) with implanted hardware
8. History of heavy alcohol use
9. Chronic pain DISEASE
10. benign prostatic hypertrophy DISEASE
11. Anxiety/depression
12. Multiple prior infections DISEASE (Reveal pocket cystitis DISEASE multiple
abscesses prostatitis DISEASE )
13. Dysphagia DISEASE
14. Tobacco abuse


Social History:
smokes 1ppd ongoing 13 years admits to 3 beers a night. He was
a manager in retail now applying for disability


Family History:
non-contributory

Physical Exam:
From clinic [**8-12**]
Gen: anxious uncomfortable gentleman in no acute distress. HR
100 and BP 146/100
HEENT: Pupils: PERRL EOMs intact
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Awake and alert cooperative with exam normal
affect.
Orientation: Oriented to person place and date.
Language: Speech fluent with good comprehension and repetition.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light Visual fields
are
full to confrontation.
III IV VI: Extraocular movements DISEASE intact bilaterally without
nystagmus DISEASE .
V VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX X: Palatal elevation DISEASE symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius DISEASE normal bilaterally.
XII: Tongue midline without fasciculations DISEASE .

Motor: Normal bulk and tone bilaterally. No abnormal movements DISEASE
tremors DISEASE . Strength full power [**5-30**] throughout except in shoulders
[**4-30**]. No pronator drift. Gait is slow

Sensation: Intact to light touch
Reflexes: 3 Admission Date: [**2198-6-17**] Discharge Date: [**2198-7-6**]

Date of Birth: [**2149-8-22**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Sepsis DISEASE

Major Surgical or Invasive Procedure:
HD cath placement
PICC line placement


History of Present Illness:
48M in USOH until two nights ago developed Admission Date: [**2185-12-22**] Discharge Date: [**2186-1-4**]


Service:

HISTORY OF PRESENT ILLNESS: The patient is an 88 year-old
female with a history of coronary artery disease DISEASE status post
coronary artery bypass graft times two congestive heart
failure with ejection fraction of 35% paroxysmal atrial
fibrillation DISEASE status post DDD pacer placement admitted
[**2185-12-22**] with sudden onset of right eye pain DISEASE at home. She
subsequently developed slurred speech DISEASE and was taken to the
Emergency Department via EMS. In the Emergency Department
the patient was noted to have slurred speech DISEASE and a left
hemiparesis DISEASE . CAT scan was negative for hemorrhage DISEASE but
positive for a probable embolic right MCA stroke DISEASE . TPA was
administered in the Emergency Department without benefit.
The patient developed respiratory distress DISEASE in the Emergency
Department requiring supplemental oxygen Lasix and a trial
of a noninvasive ventilator.

The patient was subsequently transferred to the MICU. Blood
pressure was elevated on admission to 160 to 180. Symptoms
of congestive heart failure DISEASE were controlled with a
nitroglycerin drip initially. Neurological examination
revealed complete left sided hemiplegia DISEASE with decreased
sensation of the left arm and a left facial droop. The
patient has required no further diuresis in the MICU. Blood
pressures were running in the 120s to 130s. Nitroglycerin
drip was discontinued on [**2185-12-22**] upon arrival to the Medical
Intensive Care Unit. Speech and swallow evaluation on
[**2185-12-23**] recommended nectar thick liquids since the patient
was considered to be at aspiration risk. A repeat head CT on
[**12-22**] showed a large right MCA stroke unchanged from prior.
The patient's creatinine was slightly increased from
baseline but her urine output was good. An increased white
blood cell count was noted on [**12-22**] considered to be stress
response versus evidence of infection DISEASE and cultures were sent.

On [**12-22**] and [**12-23**] the patient was noted to have increased
alertness complaining of a headache DISEASE with an unchanged
neurological examination. On [**12-23**] systolic blood pressure
was running 100 to 110 with the head of the bed at 30 degrees
elevation. The patient was alert and interactive though not
opening her eyes. She was subsequently transferred to the
floor.

PAST MEDICAL HISTORY: 1. Coronary artery disease status
post coronary artery bypass graft times two in [**2181**]
complicated by a left ventricular aneurysm DISEASE status post
patched graft and third degree heart block DISEASE . 2. History of
paroxysmal atrial fibrillation DISEASE status post DDD pacer. 3.
Congestive heart failure DISEASE with ejection fraction of 35%. 4.
Hypertension DISEASE . 5. Hyperthyroid. 6. Chronic renal
insufficiency with a baseline creatinine of 1.4.

MEDICATIONS AT HOME: Cozaar 25 mg po q.d. Lasix 40 mg po
q.d. enteric coated aspirin Ambien Lipitor Levoxyl.

MEDICATIONS AT MICU: Protonix 40 mg q.d. Tylenol subQ
heparin and enteric coated aspirin.

ALLERGIES: No known drug allergies DISEASE .

PHYSICAL EXAMINATION ON TRANSFER FROM THE MICU: Vital signs
temperature 98.2. Pulse 61. Blood pressure 121/56.
Respiratory rate 20. Pulse ox 100% on room air.
Examination the patient is lying in bed with her eyes
closed unable to open them but is interactive and responds
to questions and commands. Mental status the patient is
oriented to hospital state but not year. She is oriented
to the reason for her hospitalization and answers questions
appropriately. HEENT she has dry oral mucosa. The tongue is
midline. She is unable to raise her eyelids. The pupils are
poorly reactive bilaterally but the patient does respond to
light stimuli. There is poor response to threat bilaterally.
We were unable to assess visual fields and extraocular
movements at this time. Neck was supple with no bruits.
Cardiovascular regular 2 out of 6 systolic murmur best at
the right upper sternal border. Lungs were with rhoncerous
breath sounds bilaterally in the anterior lung fields.
Abdomen is soft mild diffuse tenderness to palpation with
no rebound or guarding and active bowel sounds DISEASE . Extremities
no edema DISEASE . There are several small raised red lesions on the
distal lower extremities.

Neurological examination the patient's sensation is intact.
The patient is able to open her jaw against resistance and
shrug her shoulders. She has a left sided visual field
defect/neglect. Sensation there is no response to light
touch to the left arm. She does sense touch on the right
arm. Light touch sensation is intact bilaterally in the
lower extremities. Strength of the left arm is flaccid DISEASE with
0 out of 5 strength. The left leg is also flaccid DISEASE . The
right arm shows 5 out of 5 biceps and triceps. The right leg
3 out of 5 hip extension 5 out of 5 ankle flexion and
extension. Reflexes biceps 2Admission Date: [**2130-11-14**] Discharge Date: [**2130-11-27**]

Date of Birth: [**2058-9-27**] Sex: F

Service: SURGERY

Allergies DISEASE :
Latex / Penicillins / Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Abdominal painAdmission Date: [**2161-7-15**] Discharge Date: [**2161-7-19**]

Date of Birth: [**2124-7-27**] Sex: F

Service: NEUROSURGERY

Allergies DISEASE :
Shellfish / Scopolamine

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache DISEASE

Major Surgical or Invasive Procedure:
[**2161-7-15**] DECOMPRESSION CRANIECTOMY FOR CHIARI MALFORMATION WITH
DURAPLASTY


History of Present Illness:
36 yo F with a long-standing history of fronto-occipital
headaches DISEASE previously treated with NSAIDs and sumatriptan also
been seen at the pain DISEASE clinic with trials of lidocaine and
ketorolac infusions as well as injections of lidocaine and
steroids all to no avail recently started on amitryptiline 10
mg
po daily.
She notes a history of headaches DISEASE since adolescence and these
have continued to progress. She complains of a constant headache DISEASE
of moderate severity which is bilateral and fronto-occipital.
However whenever she performs any type of Valsalva including
coughing sneezing DISEASE or heavy lifting she notes a different
more severe headache DISEASE mostly occipital in nature with associated
nausea vomiting DISEASE photo/phonophobia and flashing lights
sensation. She underwent an MRI on [**2161-5-4**] which showed a
Chiari I malformation DISEASE . This was followed by an MRI C-spine DISEASE which
showed no syringomyelia DISEASE .


Past Medical History:
PAST MEDICAL HISTORY
hyperthyroid DISEASE no meds

PAST SURGICAL HISTORY
-T&A
-ear tubes
-bilateral urethral stents as a child
-orthopedic surgery to R leg (4 total)


Social History:
nurse married 2 children social EtOH no tobacco but
significant 2nd hand smoke growing up no illicits


Family History:
ruptured cerebral aneurysm DISEASE requiring surgery in 50s COPD DISEASE
CAD ureteral reflux resulting in ESRD DISEASE requiring kidney
transplantAdmission Date: [**2138-2-16**] Discharge Date: [**2138-2-17**]


Service: MEDICINE

Allergies DISEASE :
Codeine / Epinephrine

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Drug ingestion.
Reason for MICU admission: Suspected overdose DISEASE on verapamil
metformin.


Major Surgical or Invasive Procedure:
None.


History of Present Illness:
(History obtained via daughter)
This 83 year old woman with a history of dementia hypertension DISEASE
and diabetes DISEASE was taken to ED after it was discovered that she
may have taken three doses of all her morning medications.
Dementia DISEASE at baseline so unable to give details. Her son visited
this AM at 10:30 and noticed his mother felt dizzy. He found an
open pill box and noticed doses for medications over three days
were missing. She usually takes these medications at 8:30 AM. On
weekdays an aide helps her with this but on weekends the
patient takes the medications herself. Morning medications
included: glucosamine Verapamil XL (180 per daughter) tylenol
(1000 mg) namenda razadyne (an anticholinesterase inhibitor)
and metformin 500 mg. They contact[**Name (NI) **] her PCP who advised to
bring her to the ED. On arrival vital signs were: HR 95 BP
173/87. FS 101. EKG unremarkable. She did have one episode of
diarrhea DISEASE and one episode of vomiting DISEASE . She underwent charcoal
therapy on recommendation of toxicology consult and was
subsequently admitted to ICU for intensive monitoring.
.
THe patient has not been depressed DISEASE and there is no history of
her trying to harm herself.
.
ROS: Denies fevers chest pain dyspnea abdominal pain DISEASE . Admission Date: [**2190-3-4**] Discharge Date: [**2190-3-9**]

Date of Birth: [**2114-7-18**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Fall down stairs with neck and back pain DISEASE

Major Surgical or Invasive Procedure:
[**3-4**] Closed reduction an splinting bilateral radial fractures DISEASE

History of Present Illness:
This is a 75 year old woman s/p mechanical fall down 15 stairs
and was found at bottom of stairsAdmission Date: [**2177-11-25**] Discharge Date: [**2177-12-5**]

Date of Birth: [**2114-2-8**] Sex: M

Service: [**Hospital1 139**]

HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
male with a past medical history of chronic obstructive pulmonary disease lung cancer DISEASE status post right
pneumonectomy in [**2175-1-26**] complicated by pulmonary artery
laceration status post transtracheal catheter placement for
oxygen and suctioning who was in his usual state of health
until [**2177-11-24**] when he developed nausea DISEASE lower
abdominal pain DISEASE and projectile vomiting DISEASE of nonbloody emesis DISEASE .
He presented to the [**Hospital6 256**]
Emergency Room on [**2177-11-25**]. At that time he denied
diarrhea constipation fevers chills hematochezia DISEASE and
bright red blood per rectum. He had dark stools at baseline
secondary to iron use. The stool was found to be guaiac
positive in the Emergency Department. In the Emergency
Department also his hematocrit value was 19 down from a
baseline of 31 one month previously and he was coagulopathic DISEASE
with an INR of 9.8. Attempts to place a nasogastric tube in
the Emergency Department were unsuccessful. While in the
Emergency Department he was transfused 4 units of packed red
blood cells 2 units of fresh frozen plasma and got 2 mg of
subcutaneous Vitamin K. The patient was admitted to the
Medicine Floor. Repeat hematocrit several hours later
dropped to a value of 13. The nasogastric tube was placed on
the floor with nasogastric lavage negative for fresh blood.
He was at that point transferred to the Medical Intensive
Care Unit. Workup while in the Medical Intensive Care Unit
included two esophagogastroduodenoscopies both without fresh
blood or old blood but demonstrating a single raised 5 to 7
cm esophageal nodule on an erythematous base at approximately
25 cm. There was no evidence of stigmata of recent bleeding DISEASE .
He was stabilized with a total of seven units of packed red
blood cells seven units of fresh frozen plasma and one unit
of platelets. He also received intravenous fluid
resuscitation with normal saline. Computerized tomography
scan of the abdomen was performed which was negative for
diverticuli perforation DISEASE or retroperitoneal bleed DISEASE .
Colonoscopy performed later in the hospital course showed
some polyps diverticulosis DISEASE of the sigmoid colon and
descending colon. Internal hemorrhoids were noted but no
stigmata of recent bleeding DISEASE . The patient's coagulopathy DISEASE was
improving. His hematocrit was stable and he was transferred
to the General Medicine Floor DISEASE on [**2177-11-28**]. Of note
prior to transfer he developed swelling DISEASE of the right upper
extremity and complained of pain DISEASE of the right upper
extremity. Doppler ultrasound was performed which showed
evidence of a right axillary deep vein thrombosis DISEASE .

PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary
diseaseAdmission Date: [**2193-3-24**] Discharge Date: [**2193-4-9**]

Date of Birth: [**2134-8-28**] Sex: F

Service: SURGERY

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Crampy abdominal pain DISEASE

Major Surgical or Invasive Procedure:
Right colectomy with cholecystectomy ([**3-26**])
Percutaneous drain placement ([**4-1**])
Re-exploration ([**4-2**])


History of Present Illness:
Ms [**Known lastname 4698**] is a 58-year-old woman complaining of abdominal
pain DISEASE a history of previous sigmoidectomy for diverticular
disease. The patient complains of cramps DISEASE and vomiting DISEASE when N/G
tube not to aspiration.

Physical Exam:
Pertinent positives/negatives on Admission mildly obese soft
abdomen. No Rebound/guarding. No rigidity DISEASE . Light diffuse
tenderness DISEASE . No hernia DISEASE .

Pertinent Results:
[**2193-3-24**] 12:30PM WBC-10.9 RBC-4.74 HGB-14.7 HCT-42.4 MCV-89
MCH-31.1 MCHC-34.7 RDW-13.5
[**2193-3-24**] 12:30PM NEUTS-79.9* LYMPHS-14.9* MONOS-3.3 EOS-1.7
BASOS-0.2
[**2193-3-24**] 12:30PM PLT COUNT-395
[**2193-3-24**] 12:30PM ALT(SGPT)-32 AST(SGOT)-18 ALK PHOS-86 TOT
BILI-0.6
[**2193-3-24**] 12:30PM LIPASE-29
[**2193-3-24**] 12:30PM GLUCOSE-126* UREA N-9 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
[**2193-3-24**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG

Brief Hospital Course:
Patient underwent CT scan which was consistent with a
mesenteric mass near the cecum. Proceeded with exploratory
laparotomy with planned wedge resection of mesenteric mass
requiring right colectomy on [**3-26**]. She underwent right colectomy
for obstructing ascending colon from an isolated giant
diverticula DISEASE . The patient at
operation noted to have a markedly inflamed gallbladder
pathology consistent with chronic cholecystitis DISEASE and open
cholecystectomy was performed at that time. Postoperatively the
patient was evaluated for tachycardia DISEASE and underwent a CAT
scan which was suggestive of a right upper quadrant fluid
collection. HIDA scan revealed a leak which was confirmed by
ERCP. Endoscopic biliary stents were placed for better drainage
of a duct of Luschka leak from the hepatic fossa. It was
recommended in consultation with Dr. [**First Name (STitle) **] and Dr.[**Last Name (STitle) **] to
proceed with a percutaneous drainage of fluid collection by
interventional radiology on [**4-1**]. Postoperative hematocrit
showed a change from 33 to 22. The patient was tachycardiac
transfused two units of blood and returned to the operating room
for exploration on [**4-2**]. Patient was kept in the ICU intubated.
Patient was extubated on [**4-5**]. She was subsequently transferred
out of the unit. Patient was deemed stable and suitable for
discharge on [**4-8**]. JP x 2 were removed on discharge.


Medications on Admission:
Singulair 10'Admission Date: [**2189-9-4**] Discharge Date: [**2189-9-8**]

Date of Birth: [**2118-4-3**] Sex: F

Service: MED

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 281**]
Chief Complaint:
S/p L mainstem bronchus stent removal

Major Surgical or Invasive Procedure:
Bronchoscopy with stent removal
Intubation and extubation


History of Present Illness:
71yo F with a history of stage IIIa non-small lung [**Hospital 4699**]
transferred to the MICU after rigid bronch for observation. The
patient was diagnosed with lung cancer DISEASE in 4/00 and is now s/p
RUL lobectomy carboplatin tx and radiation tx. Since then she
has had multiple bronchoscopies including placement of a stent
into the L main bronchus in [**4-1**]. On [**8-20**] she had a
bronchoscopy which revealed significant narrowing of L main
bronchus with formation of granulation tissue. She underwent
rigid bronchoscopy on the day of admission ([**2189-9-4**]) showing
almost 95 percent obstruction of the left mainstem bronchus. She
was treated with stent removal debridement of a large amount of
granulation tissue and argon laser coagulation.
The patient was felt to be at risk for airway collapse and
bleeding DISEASE after the procedure and was not extubated. She was
transferred to the MICU from the PACU for further monitoring and
evaluation.

Past Medical History:
1. Right upper lobe lung cancer ( adenocarcinoma DISEASE stage III). In
[**4-/2185**] right wedge biopsy - adenocarcinoma DISEASE . In 04/00 right
upper lobe lobectomy. Positive hilar/paratracheal node
involvement.
2. Hypothyroid DISEASE .
3. Hyperlipidemia DISEASE
4. Right arm surgery (Admission Date: [**2186-9-29**] Discharge Date: [**2186-10-13**]

Date of Birth: [**2133-2-21**] Sex: F

Service:

CHIEF COMPLAINT: Metastatic thyroid cancer DISEASE to the lungs.

HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old
female with a history of hypertension DISEASE non-insulin-dependent
diabetes mellitus DISEASE and a long history of multinodular goiter DISEASE
which has doubled in size recently. The patient was admitted
on [**8-/2186**] and found to have D-differential papillary
carcinoma DISEASE on fine-needle aspiration. The patient was also
found to have multiple pulmonary nodules on chest CT and
chest x-ray at that time and the patient was admitted on
[**2186-9-13**] with shortness of breath DISEASE and aspirate of right
lower lobe nodule at that time revealed malignant cells. The
patient was scheduled for total thyroidectomy with the
surgery team on [**9-29**] with plan to pursue adjuvant
chemotherapy and XRT to the surgical bed. The patient was to
receive carboplatinum and Taxol as the chemotherapeutic
regimen. The patient had a CAT scan at that time which
revealed multiple pulmonary nodules. The patient presented
with progressive shortness of breath nonproductive cough DISEASE
right sided chest discomfort. Postoperatively the patient
had increased hypoxia DISEASE . The patient was found to have small
PEs on CT angiogram. The patient was heparinized and
coumadinized at that time. The patient was started on
decadron prechemotherapy and the course was complicated by
possible pneumonia DISEASE on chest x-ray. There was no complaints
of chest pain nausea vomiting abdominal pain DISEASE or pleuritic DISEASE
chest pain DISEASE that the patient recalls.

PAST MEDICAL HISTORY:
1. Thyroid cancer DISEASE tissue biopsy awaiting diagnosis with
pulmonary metastasis DISEASE diagnosed by FMA as D-differentiated
papillary carcinoma DISEASE versus medullary carcinoma DISEASE .
2. Multinodular goiter DISEASE times 34 years.
3. Hypertension.
4. Non-insulin-dependent diabetes mellitus DISEASE on oral
hypoglycemics.

MEDICATIONS ON ADMISSION:
1. Glucophage b.i.d.
2. Uniretic 25/15 q.d.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS ON TRANSFER: Medications upon transfer to the
medicine service were as follows:
1. Regular insulin sliding scale.
2. Tums 500 mg t.i.d.
3. Albuterol nebs q.6 hours p.r.n.
4. Levofloxacin 500 mg q.d.
5. Levoxyl 100 mg q.d.
6. Lopressor 50 mg b.i.d.
7. ....................20 mg PO q.d.
8. Protonix 40 mg q.d.
9. Oxycodone p.r.n.
10. Morphine IV q.4h. to q.6.p.r.n DISEASE .
11. Albuterol and Atrovent MDIs.

SOCIAL HISTORY: The patient lives with her daughter. T was
born in [**Location (un) 4708**]. The patient was a day care provider and
has three children. The patient denies tobacco or alcohol
use.

FAMILY HISTORY:
1. Hypertension DISEASE .
2. Admission Date: [**2193-11-18**] Discharge Date: [**2193-11-26**]

Date of Birth: [**2154-4-7**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Oxycodone

Attending:[**Male First Name (un) 4578**]
Chief Complaint:
.
Right patellar fracture DISEASE
.

Major Surgical or Invasive Procedure:
.
1. open reduction internal fixation for right patellar fracture DISEASE
.
2. Cardiac catheterization
.


History of Present Illness:
CC:[**CC Contact Info 4714**].
HPI: 39 yo M w h/o G6PD deficiency DM2 DISEASE s/p ORIF (intubated
during procedure) for R patella fx. Post-surgical course
complicated by 02 desat to the 80's on RA DISEASE and post-op pain DISEASE . Pt.
required 6L FM 02 to incr. sats to the 90's. Additionally EKG
showed diffuse ST depressions DISEASE and TWI. Pt. was transferred to
the [**Hospital Unit Name 153**] for observation and management of hypoxia DISEASE . The pt. had
an epidural placed for pain DISEASE control which has now been d/c'd. He
is now transferred to [**Hospital Unit Name 196**] for further workup of EKG changes and
possible cardiac catheterization. He denies any chest pain DISEASE or
SOB during this hospitalization.
.
ROS: Pt. denies headaches DISEASE SOB CP(although he does describe a
few episodes of chest pain DISEASE with excercise and at rest in the
past). Denies N/V DISEASE denies diarrhea DISEASE admits to constipation DISEASE and
reflux as inpatient.
.


Past Medical History:
.
- OSA(newly diagnosed)
- G6PD deficiency
- DM 2
- h/o genital herpes DISEASE
- R patella fx: occurred while playing basketball on [**11-8**].
Underwent ORIF of R knee on [**11-18**] due to non-[**Hospital1 **].
- s/p repair of R ruptured patellar tendon in [**2185**]
.

Social History:
.
SOCIAL HISTORY: He is currently working as a realtor. He does
not smoke never smoked in the past but does drink alcohol
socially.
.


Family History:
.
FAMILY HISTORY:
No fam hx of CAD or cancer DISEASE .
.


Physical Exam:
.
PHYSICAL EXAM DISEASE :
Vitals: 140/84 68 100%RA FS 153
Gen: NAD AAOx3
HEENT: EOMI PERRL
Cardio: distant heart sound normal S1/S2 no murmurs.
Resp: CTA bilat. no wheezes crackles
Abd: NT/ND DISEASE BS normoactive
Ext: R knee immobilizer in place 1Admission Date: [**2109-8-7**] Discharge Date: [**2109-8-17**]

Date of Birth: [**2053-7-14**] Sex: F

Service:






DR.[**Last Name (STitle) **][**First Name3 (LF) 275**] E. 02-248



Dictated By:[**Dictator Info **]

MEDQUIST36

D: [**2109-8-17**] 13:51
T: [**2109-8-22**] 08:45
JOB#: [**Job Number 4718**]
Admission Date: [**2109-8-7**] Discharge Date: [**2109-8-17**]

Date of Birth: [**2053-7-14**] Sex: F

Service: CARDIOTHORACIC

HISTORY OF PRESENT ILLNESS: This is a 56 year-old woman who
had a preop electrocardiogram for a spinal surgery that was
notable for ischemic changes. She underwent a stress
echocardiogram on [**7-5**] that demonstrated inferior wall
near akinesis. On [**8-2**] she underwent a cardiac
catheterization that revealed a 50% occlusion of her LAD and
a 90% occlusion of her left circumflex as well as a 100%
occlusion of the RCA. She had an echocardiogram that
demonstrated an ejection fraction of approximately 40%. The
decision was made that the patient should undergo a coronary
artery bypass surgery.

MEDICATIONS ON ADMISSION: Rocaltrol 0.625 mg q.d.
Nephrocaps 1 mg po q.d. Lipitor 10 mg po q.d. Provera 2.5
mg po q.d. Premarin 0.625 mg q.d. Norvasc 5 mg po b.i.d.
Gabapentin 100 mg po t.i.d. and Dilaudid 4 mg po q.i.d.

PAST MEDICAL HISTORY: 1. Stable angina DISEASE . 2. Type 2 insulin
dependent diabetes mellitus DISEASE on hemodialysis and neuropathy DISEASE .
3. Hypertension. 4. Hypercholesterolemia. 5.
Degenerative joint disease DISEASE at the L4-L5 interspace.

HOSPITAL COURSE: The patient was admitted on [**2109-8-7**] to the [**Hospital Unit Name 196**] Service. On [**8-8**] the patient
underwent an uncomplicated coronary artery bypass graft times
three with the left internal mammary coronary artery to the
left anterior descending coronary artery saphenous vein
graft to the obtuse marginal 1 and the saphenous vein graft
to the right posterior descending coronary artery. The
patient tolerated the procedure well and was transported to
the CSRU intubated and in stable condition.

Immediately postoperative the patient was able to answer
questions and follow commands. She was weaned off of the
ventilator and extubated. Her chest tube was notable for a
small air leak initially. On postoperative day one she was
started on Lopressor as well as aspirin. She was weaned from
the Levophed and started on a renal diet. Her pleural chest
tube was left in place and the Renal Service was consulted
for management of her dialysis. At that time she was being
atrially paced at 80 over a normal sinus rhythm at 60. Her
Levophed was discontinued and she was weaned from the
Milrinone. She underwent hemodialysis. On postoperative day
two the patient's heart rate was in the 80s with sinus rhythm
with a blood pressure of 118/67. Her pacemaker was
subsequently turned off as it was competing with her
underlying rhythm. She was stable and was transferred to the
floor.

On the floor the [**Hospital 228**] hospital course was uneventful.
She remained afebrile with good pain DISEASE control and maintaining
a sinus rhythm. She experienced some nausea DISEASE and some emesis DISEASE
associated with her potassium supplements. Her blood sugars
were well controlled but she was somewhat anorexic. She
also began complaining of some mild mid epigastric tenderness DISEASE
on postoperative day five associated with some nausea DISEASE . She
was also noted to have an elevated white blood cell count of
24000 as well as mildly elevated transaminase and alkaline
phosphatase levels. She underwent a KUB which was notable
for her colon being full of stool. She also had a right
upper quadrant ultrasound that was negative for biliary
disease processes. She was begun on a regimen of Cascara and
Milk of Magnesia with subsequent large bowel movements DISEASE with
relief of her abdominal pain DISEASE . She was noted to have a
somewhat swollen right lower extremity which was the site of
the saphenous vein graft and concern for a possible deep
venous thrombosis DISEASE as the etiology of the increased white
blood cell count prompted a venous duplex ultrasound. The
result of this study was negative for deep venous thrombosis DISEASE .

By postoperative day nine the patient had remained afebrile
and her white count had steadily declined to 17400. The
patient was subsequently discharged with instructions to
return to clinic and/or the Emergency Department if she
should become ill.

PHYSICAL EXAMINATION ON DISCHARGE: The patient was afebrile
with stable vital signs. She was in no acute distress alert
and oriented. Her lungs were clear. Her sternum was stable.
Her incision was clean dry and intact. Her heart had a
regular rate and rhythm and a 2/6 systolic ejection murmur at
the base. Her belly was soft nontender nondistended. Her
extremities were warm and well profused and her incision was
clean dry and intact. She had a small amount of swelling DISEASE on
her right lower extremity.

DISCHARGE MEDICATIONS: Lopressor 12.5 mg po b.i.d. Percocet
one to two tablets po q 3 to 4 hours prn pain DISEASE Colace 100 mg
po b.i.d. ECASA 81 mg po q.d. Ibuprofen 400 mg po t.i.d.
Gabapentin 100 mg po t.i.d. Amiodarone 400 mg po b.i.d.
times seven days and then 400 mg po q.d. Nephrocaps one
tablet q.d. Premarin 0.625 mg po q.d. Rocaltrol 0.5 mg po
q.d. Provera 2.5 mg po q.d.

The patient was subsequently discharged in stable condition
with instructions to return to the clinic or the Emergency
Department if she was feeling ill and to follow up with Dr.
[**Last Name (STitle) 1537**] in one weeks time as well as her primary care physician
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] in one to two weeks time. She is sent home with
plans for [**Location (un) 86**] VNA to come in and check on her for home
safety and cardiopulmonary evaluation.






[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**] M.D. [**MD Number(1) 1540**]

Dictated By:[**Last Name (NamePattern1) 3801**]

MEDQUIST36

D: [**2109-8-17**] 14:19
T: [**2109-8-22**] 08:46
JOB#: [**Job Number 4719**]
Admission Date: [**2109-9-27**] Discharge Date: [**2109-10-25**]

Date of Birth: [**2053-7-14**] Sex: F

Service: Cardiothoracic Surgery

HISTORY OF PRESENT ILLNESS: This is a 56-year-old woman with
non-insulin DISEASE dependent diabetes mellitus DISEASE coronary artery
disease status post three vessel coronary artery bypass
graft in [**8-3**] end stage renal disease DISEASE on hemodialysis
rushed to the [**Hospital1 69**] Emergency
Room with fever DISEASE for three days shortness of breath DISEASE and right
sided chest pain DISEASE . She has been meanwhile at home receiving
visiting nurse care. She states the fever DISEASE at home was as
high as 101.4 degrees. She was previously admitted to CT
surgery service for median sternotomy wound drainage which
required IV antibiotics and wound debridement. At home she
denies any productive cough wheezing or wound drainage. The
symptoms were first noticed by the patient two days ago and
have worsened over the past several days.

PAST MEDICAL HISTORY: As described in history and physical.

MEDICATIONS: On admission Aspirin 81 mg po q day Premarin
0.625 mg po q day Norvasc 5 mg po bid Trazodone
Hydroxyprogesterone Neurontin 300 mg po bid Ultram 50 mg po
q day Lipitor 10 mg po q day Pravachol 0.25 mg po q day
Lopressor 12.5 mg po bid.

ALLERGIES: No allergies DISEASE .

PAST SURGICAL HISTORY: Status post CABG times three on
[**2109-8-8**].

PHYSICAL EXAMINATION: On admission T max 101.5 blood
pressure 106/70 pulse 88 respirations 16 FAO2 90% on five
liters. In general alert and oriented times three
conversant pulmonary clear to auscultation left decreased
breath sounds at the right base. CV regular rate and
rhythm. Chest wall sternotomy wound the bottom half of the
midline sternotomy incision is opened with fibrinous exudate
and 0 drainage. There is a click appreciated when the
patient coughs. Abdomen soft nontender non distended.
Right saphenectomy site small area of erythema DISEASE and a large
amount of scab. Both feet are warm. There is trace edema DISEASE in
the right lower extremity.

Pertinent studies: Chest x-ray bilateral pleural effusion DISEASE
no evidence of CHF effusion DISEASE is greater on the right side vs
the left. Chest no pulmonary embolism DISEASE no infiltrate or
consolidation some modest right effusion with right lower
lobe atelectasis small left effusion small amount of fluid
in the anterior mediastinum no pneumomediastinum DISEASE .

Labs CBC with white count 14.0 hematocrit 27.2 platelet
count 330000 differential of 95% neutrophils 0% bands.
Chemistries sodium 135 potassium 5.2 chloride 93 CO2 28
BUN 54 creatinine 6.7 glucose 264.

HOSPITAL COURSE: The night of admission a thoracentesis was
performed in the right posterior thorax. Approximately 500
cc of fluid was removed. Also on the night of admission the
saphenectomy wound was sharply debrided the bleeding DISEASE tissue
impacted with wet to dry dressing and normal saline and the
sternal wound was sharply debrided. The granulation tissue
was packed with wet to dry dressings and normal saline. The
patient was empirically started on Piperacillin and
Vancomycin. Plastic surgery was consulted they recommended
conservative management as was being performed by general
surgery. The patient was also seen by the renal service who
managed the patient's dialysis and electrolyte management
during the hospitalization. PICC line was placed in
anticipation of a long course of IV antibiotics. On [**9-30**] a
VAC dressing was first placed in the wound. The patient was
doing well on intravenous antibiotics and VAC dressing
changes.

The [**Hospital 228**] hospital course faltered when at hemodialysis
increased venous pressures were noticed on [**10-1**]. On [**10-2**]
fistulogram revealed a clotted fistula DISEASE and the patient was
unable to receive her normal dialysis on [**2109-10-3**]. Transplant
surgery saw the patient and scheduled her for revision.
During the interim Quinton catheter was placed in the
patient's right groin for dialysis. On the evening of
[**2109-10-4**] the patient fell getting out of bed. When the house
officer arrived the patient was confused in bed and somewhat
difficult to arouse. CT scan of the head performed on an
emergent basis demonstrated no intracranial pathology.
Initially the skull was intact. The next morning the patient
was difficult to arouse and her labs reflected the fact that
she had not been dialyzed in several days with a rising BUN
creatinine and potassium. The patient was given Kayexalate
for the rising potassium. A repeat CT scan of the head was
similar to the previous CT scan in that there was no evidence
of intracranial pathology. At this point the patient had an
episode of bradycardia DISEASE with wide QRS complexes. She lost
consciousness. After receiving an amp of D50 insulin and
Calcium Gluconate the patient was transferred to the
Intensive Care Unit. At this point her hematocrit was found
to be 13. The patient vomited a large amount of guaiac
positive material.

In the Intensive Care Unit the patient was transfused four
units of packed red cells and 4 units of FFP. The patient
was intubated and an NG tube was placed. Large amount of
bloody material was aspirated from the stomach. GI service
was consulted for an emergent EGD which revealed an enormous
amount of clot protruding from the pylorus and bright red
blood was seeping around it. The gastroduodenal artery was
visualized in the posterior wall of the duodenum. The
patient was given blood and FFP to maintain hematocrit and to
combat an ongoing coagulopathy DISEASE . On [**10-4**] the patient went to
the interventional radiology suite and had an
angioembolization of the gastroduodenal artery. At this
point patient was placed on Protonix and started on a course
of Amoxicillin and Clarithromycin in addition to the
Piperacillin and Vancomycin.

The patient received her dialysis in the ICU beginning on
[**2109-10-5**]. During this course in the Intensive Care Unit the
patient remained intubated and was repeatedly transfused to
keep her hematocrit above 30. By [**2109-10-7**] the patient's
mechanics were good enough to begin a wean from the
ventilator and by [**10-18**] she was extubated. By [**10-11**] the
patient was transferred to the patient care floor. The
patient continued to do well on the floor the VAC dressing
changes to the sternum were continued and the size of the
sternal wound had decreased with time. Additionally the
saphenectomy sites were cared for with wet to dry dressings
which were changed over to santyl dressings twice a day.
Both wounds were intermittently debrided to reveal viable
tissue.

On [**2109-10-15**] the transplant surgery service deemed the patient
an operable candidate and brought her to the operating room
for fistular revision. Please see previously dictated
operative note for more details.

After the fistula DISEASE revision the patient was able to use her
fistula DISEASE for hemodialysis and the Quinton catheter was
removed. The VAC dressing changes continued. The [**Hospital 228**]
hospital course was complicated further by a brief episode of
C. difficile colitis DISEASE . For this the patient was treated with
Flagyl for 10 days and remained on Piperacillin and
Vancomycin. By [**2109-10-26**] the patient was accepted to
[**Hospital3 **]. At this point patient's wounds were stable
she had a PICC line in place was tolerating po and was ready
to go to rehabilitation.

CONDITION ON DISCHARGE: Stable.

DISCHARGE DISPOSITION: To rehab.

DISCHARGE MEDICATIONS: Regular insulin sliding scale as
follows: Glucose 150-200 gets 2 units 201-250 gets 4 units 251-300 gets 6 units 301-150 8 units Epogen 14000 units q
hemodialysis Vitamin A D Zinc ointment to affected area
tid Vancomycin 500 mg IV after hemodialysis times 6 weeks
Neurontin 500 mg po bid Norvasc 5 mg po bid Trazodone 100
mg po q h.s. Lopressor 25 mg po bid Lipitor 10 mg po q
h.s. Piperacillin 3 gm IV q 8 hours for 6 more weeks
Captopril 12.5 mg po q 8 hours Protonix 40 mg po q day
Miconazole powder applied to affected areas prn Morphine
Sulfate 2 mg IV before dressing changes.

DISCHARGE DIAGNOSIS:
1. Sternal wound infection DISEASE .
2. Infection of saphenectomy site.
3. Gastrointestinal bleed DISEASE status post embolization.
4. C. difficile colitis DISEASE .




[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**] M.D. [**MD Number(1) 1540**]

Dictated By:[**Last Name (NamePattern4) 4722**]
MEDQUIST36

D: [**2109-10-25**] 19:17
T: [**2109-10-25**] 19:31
JOB#: [**Job Number 4723**]
Admission Date: [**2168-8-3**] Discharge Date: [**2168-8-8**]

Date of Birth: [**2132-1-31**] Sex: F

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Myasthenia DISEASE [**Last Name (un) 2902**] in the post-partem period

Major Surgical or Invasive Procedure:
Trans-sternal thymectomy with mediastinal lymphadenectomy


History of Present Illness:
Ms. [**Known lastname 4735**] is a 36 yo F who in the early postpartum period
developed a weakness syndrome DISEASE which eventually was diagnosed as
myasthenia DISEASE [**Last Name (un) 2902**] based on
standard serologies and a Tensilon test. She unfortunately has
been refractory to medical management. A CT scan showed no
thymoma DISEASE but fullness of the thymus. After consultation with her
neurologist we recommended thymectomy as an adjunct to her
management.

Past Medical History:
1. G1P1 with delivery of healthy baby girl [**2167-9-17**]
2. Status post tonsillectomy

Social History:
She is married with one child. Works [**Street Address(1) 4736**] Bank as a
portfolio manager. No history of tobacco alcohol or illicit
drug use.


Family History:
No family history of neurologic or other autoimmune disease DISEASE .


Physical Exam:
At time of discharge:

A&O X 3 NAD
Tachycardic no murmur appreciated
Lungs CTAB no w/r/r
Midline sternotomy dressing c/d/iAdmission Date: [**2152-3-23**] Discharge Date: [**2152-3-25**]

Date of Birth: [**2079-4-19**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Shortness of Breath DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Patient is 72 year Spanish speaking male with PMHx of
Parkinson's Disease DISEASE who presents to the ED for complaints of
shortness of breath DISEASE . Per patient daughter he was at his baseline
health until night prior to admission when patient described
shortness of breath and sensation DISEASE that his airways were blocked.
Patient was seen at [**Hospital1 112**] a few weeks ago for similar symptoms.
Per daughter etiology of shortness of breath DISEASE was not identified
and thought breathing difficulty could be due to anxiety DISEASE .
Patient denies any chest pain DISEASE or diaphoresis DISEASE and is symptoms do
not seem to coorelate with any medications. He has noticed no
change in his speech or any trouble with swallowing or eating
and drinking foods.
During this episode of shortness of breath DISEASE at home patient
seemed anxious and paramedics were called. While they were
present
he had brief unresponsiveness and was found to be in atrial
fibrillation DISEASE . A nasal trumpet was placed with return of
responsiveness and of sinus rhythm. He was brought to [**Hospital1 18**]. On
arrival to ICU patient comfortable denies any shortness of
breath. He has a nasal trumpet in place. His O2Sat remains above
90% on room air but appears to drop when patient falls asleep.
Patient denies any swelling DISEASE of his throat or airway he just
feels congested in his nasal passages.
.
ROS: Patient denies any CP HA n/v fevers chills cough DISEASE
abdominal pain DISEASE . Patient is urinating normally and besides
constipation DISEASE has normal bowel movements DISEASE . His Parkinson's has
gotten worse over the last year but no acute worsening over the
past few months.


Past Medical History:
Parkinson's disease DISEASE diagnosed at age 66 followed by Dr.
[**Last Name (STitle) 4742**]
at [**Hospital1 2025**]
PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4743**] at [**Hospital1 112**]


Social History:
Lives with wife and sister-in-law who have been limiting his
activities more recently though he did go out of the house once
last week by himself. Able to do laundry for example b/c did
it last week but not allowed by his wife (per daughter). No
tobacco EtOH drug use.


Family History:
noncontributory

Physical Exam:
T 98.1 BP 127/74 HR 77 O2Sat 93%-94% on RA DISEASE
Gen: NAD
Heent: PERRL EOMI OP clear no pharyngeal swelling DISEASE nasal
trumpet in place MM dry DISEASE .
Neck: supple no LAD
Lungs: CTA B/L
Cardiac: RRR S1/S2 no murmurs
Abd: soft NTND NABS
Ext: FROM no edema DISEASE
Neuro: AAOx3 patient with resting tremors DISEASE of UE and LE b/l
normal reflexes sensory grossly intact


Pertinent Results:
[**2152-3-23**] BLOOD WBC-12.1* RBC-4.53* Hgb-14.1 Hct-40.9 MCV-90
MCH-31.0 MCHC-34.4 RDW-13.7 Plt Ct-258
[**2152-3-23**] BLOOD Neuts-86.4* Bands-0 Lymphs-9.7* Monos-3.1 Eos-0.6
Baso-0.2
[**2152-3-23**] BLOOD PT-12.1 PTT-24.7 INR(PT)-1.0
[**2152-3-23**] BLOOD Glucose-130* UreaN-12 Creat-0.9 Na-136 K-4.0
Cl-97 HCO3-25 AnGap-18
[**2152-3-23**] BLOOD CK(CPK)-103
[**2152-3-23**] BLOOD cTropnT-Admission Date: [**2125-8-31**] Discharge Date: [**2125-9-2**]

Date of Birth: [**2059-7-11**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 552**]
Chief Complaint:
BRBPR after colonoscopy with polypectomy

Major Surgical or Invasive Procedure:
Colonoscopy


History of Present Illness:
66 y/o M with PMHx of Atrial Fib who went for colonoscopy on
[**8-29**] after holding coumadin for 3 days prior to procedure and
underwent three polypectomies-proximal transverse distal
transverse and cecum. On [**2125-8-30**] pt noted some crampy lower
abdominal pain DISEASE when he awoke and noticed a small amount of blood
in BMs. Pt went to work but was concerned with the continued
BRBPR approx 4 episodes. Pt reportes feeling dizzy when he saw
the blood in the toilet but denied any syncope DISEASE or presyncope DISEASE .
Pt initially presented to [**Hospital Ward Name **] thinking it was the ED
and medical emergency was called. Pt was found with blood on
seat of pants & e/o incontinence DISEASE .
.
Pt was transferred directly to the ED where initial VS 96.7 HR
90 BP 117/70 RR 16 and Sats 97% on RA DISEASE . Hct was down from 54 in
[**3-17**] to 39.1. Pt received 2L of NS but did not receive any
blood products overnight and am HCT was down at 29.7. Pt had an
episode of BRBPR on the floor and became tachy to 140s.
Decision was made for transfer to ICU and per GI recs pt had
already begun taking Golytely prep.
.
On arrival to ICU pt was anxious but denying any CP/SOB/Abd
pain DISEASE or nausea DISEASE . He had already taken approx half of the
golytely prep and was complaining of chills DISEASE .
.
ROS: The patient denies any fevers chills nausea vomiting DISEASE
diarrhea constipation hematemesis shortness of breath cough DISEASE
urinary frequency urgency dysuria DISEASE .

Past Medical History:
Atrial fibrillation DISEASE anticoagulated but pt has been holding
coumadin for approx 3 days prior to colonoscopy not restarted

Gout DISEASE
Hyperlipidemia DISEASE
Hypertension DISEASE

Social History:
patient lives in [**Location 745**]. He is married with 2 children. He is
an active smoker and has prior 50-pack-year cigarette history
and has never used IV drugs. He drinks alcohol rarely only on
social occasions.

Family History:
non-contributory

Physical Exam:
Vitals: T- 96.7 BP 111/67 HR 90 RR 18 Sats 100% on RA DISEASE
GEN: Well-appearing well-nourished no acute distress
HEENT: EOMI PERRL sclera anicteric no epistaxis DISEASE or
rhinorrhea MMM OP Clear
NECK: No JVD carotid pulses brisk no bruits DISEASE no cervical
lymphadenopathy DISEASE trachea midline
COR: RRR no M/G/R normal S1 S2
PULM: Lungs CTAB no apprec W/R/R
ABD: Soft NT ND Admission Date: [**2178-1-18**] Discharge Date: [**2178-1-23**]

Date of Birth: [**2114-2-8**] Sex: M

Service: [**Location (un) 259**]

HISTORY OF PRESENT ILLNESS: This is a 63-year-old male with
history of multiple medical problems who was recently
admitted to the [**Hospital6 256**] from
[**2178-11-26**] to [**2177-12-5**] with projectile vomiting DISEASE and
hematocrit of 13.

He had negative hemolysis DISEASE workup and negative EGD times two
and a colonoscopy times one. Found to have a right upper and
right lower extremity deep venous thrombosis DISEASE . [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]
filter was placed and he was transferred to [**Hospital **] Rehab
and went home in late 01/[**2177**].

He received seven units of packed red blood cells seven
units of fresh frozen plasma and one unit during previous
hospitalization and two units of packed red blood cells while
he was at [**Hospital1 **]. He had no nausea vomiting diarrhea DISEASE
abdominal pain DISEASE bright red blood per rectum.

Ten days ago his Coumadin and aspirin were continued for
planned EGD and colonoscopy with good prep. On [**2178-1-15**] he
had an EGD polyp DISEASE removed from the esophagus which was
negative. His colonoscopy revealed two polyps which were
adenomatous DISEASE without any complications.

Then on [**2178-1-17**] at about 10 p.m. he developed severe
bilateral lower abdominal pain DISEASE and bright red blood per
rectum times three at home and times two in the Emergency
Room. He denies nausea DISEASE but vomited once after GoLYTELY in
the Emergency Room. He had no change in shortness of breath DISEASE .
Denies chest pain fever chills cough wheezing dysuria DISEASE .

PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease DISEASE .
2. Lung cancer status post right pneumonectomy in [**1-/2175**]
complicated by the PA laceration.
3. Prostate cancer status post prostatectomy six years ago
but has had recently increasing prostate specific antigen and
was scheduled for an outpatient bone scan.
4. History of perioperative pulmonary embolism DISEASE . Had
[**Location (un) 260**] filter placed.
5. Atrial fibrillation DISEASE sinus rhythm with Amiodarone.
6. Hypertension DISEASE but has recently been hypotensive DISEASE .
7. Diabetes type 2 complicated by neuropathy DISEASE .
8. Gastroesophageal reflux disease DISEASE and negative history for
peptic ulcer disease DISEASE .
9. Obstructive sleep apnea DISEASE but does not tolerate continuous
positive air pressure.
10. Hypercholesterolemia DISEASE .
11. Vitamin B12 deficiency.
12. History of transient ischemic attacks DISEASE .
13. Cataracts DISEASE .
14. Trach placement for suctioning and oxygen requirement in
07/[**2176**].

ALLERGIES:
1. Doxepin.
2. Levofloxacin.
3. OxyContin.

MEDICATIONS ON ADMISSION:
1. Potassium chloride.
2. Colchicine.
3. Protonix.
4. Lasix.
5. Paxil.
6. Multivitamin.
7. Colace.
8. Senna.
9. Roxanol.
10. Tylenol with Codeine.
11. Combivent.
12. Amiodarone.
13. Neurontin.
14. Ferrous Sulfate.
15. Vitamin B12.
16. Glyburide.
17. Lipitor.
18. Scopolamine patch.
19. Advair.
20. Combivent nebulizer.

FAMILY HISTORY: Mother with coronary artery disease DISEASE .

SOCIAL HISTORY: Lives with his wife. Is retired. Does
tobacco 160-pack-year history but quit in [**2174**]. Quit
alcohol in [**2173**]. No drug use.

PHYSICAL EXAMINATION ON ADMISSION: Vitals: Temperature
98.4 pulse 94 blood pressure 100/65 respiratory rate 18
sat 96% on room air. In general he is well developed well
nourished maleAdmission Date: [**2111-8-4**] Discharge Date: [**2111-8-9**]


Service: SURGERY

Allergies DISEASE :
Penicillins / Lyrica

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Right lower extremity rest pain DISEASE with non-healing DISEASE right toe ulcer DISEASE

Major Surgical or Invasive Procedure:
Right femoro-peroneal bypass graft with lesser saphenous vein
graft


History of Present Illness:
This patient is an 85 year old male with a history of severe
coronary artery disease DISEASE s/p myocardial infarction DISEASE congestive
heart failure hypertension DISEASE who presents with chronit
unremitting right lower extremity rest pain DISEASE and a non-healing
right toe ulcer DISEASE . The patient received an extensive coronary
work-up prior to presentation and was felt to be a poor
operative candidate given his other co-morbidities. This poor
candidate status was discussed at length with the patient and
his family who remained quite insistent that despite the high
risks we procede with a limb-saving intervention

Past Medical History:
CADMI CHFHTNhypercholestremiaDUJd of rt. hiphx TISs/p left
CEA [**2094**]'sBPH s/p turn-now w frequency/nocturia

Social History:
Remote history of smoking quit 40 years ago social ETOH use.

Physical Exam:
Awake and alert NAD
RRR w/ SEM at base
Crackles at lung bases on auscultation bilaterally
Abdomen soft obese non-tender
Pulse exam: DP/PT dopplerable bilaterally

Brief Hospital Course:
The patient was admitted to the hospital and started on IV
antibiotics to treat his non-healing ulcer DISEASE . Cultures were taken
and ultimately grew out gram-positive cocci and gram-negative
rods. He was taken to the operating room on [**8-6**] for a right
femoro-peroneal bypass graft with lesser saphenous vein. The
patient initially tolerated this procedure well and was taken to
the vascular surgery ICU for recovery. On the morning of
post-operative day #2 the patient began to complain of chest
pain DISEASE and was found to have a systolic blood pressure of 85 with
elevated pulmonary artery pressures of 60/30. This picture was
concerning for an active coronary event. The patient was
immediately transferred to the cardiovascular surgery ICU for
further monitoring and treatment. An electrocardiogram showed
new lateral precordial ST-segment elevation. Troponins were
checked and were found to be rising to 0.67. At 2:30am on
post-operative day #3 the patient was found to be tachypnic and
tachcardic. Lasix was given emperically however soon after the
patient became unresponsive and asystolic DISEASE . ACLS protocol was
initiated and the patient was coded for 30 minutes without
return of cardiac function. The patient was pronounced deceased
at 3:57am.

Medications on Admission:
lasix 80mgm qamlasix 40mgm qpmplavix 75mgm'kcl
20meqAdmission Date: [**2129-1-5**] Discharge Date: [**2129-1-12**]


Service: MEDICINE

Allergies DISEASE :
Ciprofloxacin / Cisapride / Metoclopramide / Bactrim

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory Distress

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **] yo M w/ multiple medical problems (see below) who presents
from [**Hospital 100**] Rehab hypoxic and febrile DISEASE with CP and bilat
infiltrates requiring intubation in the ED. At baseline per the
son Mr. [**Known lastname 4749**] is a wheelchair bound russian speaking alert
and lively gentleman. He last saw his father on [**Name2 (NI) **] [**2129-1-2**]
and he was at his baseline. Per the records from the rehab the
patient was well up until the day of admission when he vomitted
a large ammount of bilious vomit DISEASE x2 and appeared to be shaking
and cyanotic. Vitals at the time were T 104 (rectal) BP 120/60
O2 89%on RA DISEASE . Aspiration pna was suspected and he was tx to [**Hospital1 18**]
for further care.
.
In the ED the patient was found to be febrile DISEASE to 103 but
otherwise hemodynamically stable. Patient then experienced
oxygen desaturation to 70's and was intubated. Patient was found
to have large mucous plugs on suctioning consistent with
aspiration. Dopamine was started for low BP while on vent.


Past Medical History:
CRI (b/l 1.3-1.9 1.5 yrs ago) (Cr 2.3 on [**12-28**])
Afib/CHF s/p Pacemaker EF 60% with 1Admission Date: [**2189-4-13**] Discharge Date: [**2189-4-27**]

Date of Birth: [**2119-2-12**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Penicillins / Shellfish Derived / Simvastatin

Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
SOB increasing lower extremity edema DISEASE

Major Surgical or Invasive Procedure:
IVC filter placement [**4-17**]
10U prbc transfusion
Midline placement [**2189-4-27**]


History of Present Illness:
70 year old female with h/o RA DISEASE previously on humera and mtx who
was discharged on [**2189-4-11**] when she presented with R shoulder
pain DISEASE . Her joint was tapped and it demonstrated an inflammatory
joint fluid c/w with RA DISEASE and negative for septic arthritis DISEASE . She
was discharged on ibuprofen prn. Upon return home 3 days prior
to presentation she felt very well but one day later noticed the
gradual onset of dyspnea DISEASE on exertion. She also had episodes of
chest twinges overnight which resolved within minutes. Admission Date: [**2194-11-2**] Discharge Date: [**2194-11-11**]

Date of Birth: [**2115-11-26**] Sex: F

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
STEMI and possible Aortic Dissection

Major Surgical or Invasive Procedure:
Cardiac catheterization with placement of 2 bare-metal stents to
PDA

History of Present Illness:
78 yo F w/ s/p CABG in [**2178**] w/ 2 vision stents who initially
presented to [**Hospital3 **] on [**11-1**] by ambulance with
generalized weakness DISEASE worse on the left side. EMTs noted slight
facial droop on the L side w/ weakend L sided grip and left arm
drifting. CT Scan showed no evidence of an acute process. At the
OSH her TropI were 0.02 --Admission Date: [**2201-5-25**] Discharge Date: [**2201-5-30**]

Date of Birth: [**2138-9-5**] Sex: M

Service: CSU


ADMISSION ILLNESS: The patient was admitted with mitral valve regurgitation DISEASE and atrial fibrillation DISEASE . He is a 62-year-
old patient of Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] with mitral valve disease DISEASE referred for outpatient
cardiac catheterization prior to valve surgery.

HISTORY OF PRESENT ILLNESS: This 62-year-old man has a
history of mitral valve disease DISEASE and paroxysmal atrial
fibrillation DISEASE . His most recent echocardiogram is from
[**2201-1-27**] where the EF was noted at greater than 60 percent
with mild LVH DISEASE and a mildly dilated left ventricular cavity DISEASE .
There was moderate dilation of the left atrium. The mitral
valve leaflets were myxomatous and mildly thickened with
moderate-to-severe mitral valve prolapse DISEASE and 2 plus mitral
regurgitation. His most recent stress test was in [**2197**] and
did not reveal any objective evidence of ischemia DISEASE .

He denies chest discomfort shortness of breath fatigue DISEASE or
dizziness DISEASE . In terms of his atrial fibrillation DISEASE he reports
that he has not had any episodes in several months. He is
referred not to be anticoagulated with Coumadin and is on
daily aspirin therapy along with propafenone.

Denies claudication edema orthopnea DISEASE PND or
lightheadedness.

PAST MEDICAL HISTORY: Mitral valve disease DISEASE PAF history of
remote prior DCCP and also BPHAdmission Date: [**2122-12-25**] Discharge Date: [**2122-12-29**]

Date of Birth: [**2067-2-2**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Headache malaise nausea disorientation DISEASE

Major Surgical or Invasive Procedure:
Lumbar puncture


History of Present Illness:
This is a 55 year old gentleman with chronic hypocapnia DISEASE central
sleep apnea episodic hyperventilati DISEASE onorthostatic hypotension DISEASE
and autonomic dysfunction DISEASE who is suspected to have a syndrome
related either to mitochondrial disease channelopathy DISEASE or an
uncharacterized metabolic pathway disturbance. He presented to
the ED after a particularly severe episode of his chronic
hypocapnia DISEASE . These episodes have been going on for eleven years
and have been characterized by nausea headache malaise DISEASE and
lightheadedness. Particularly bad episodes will lead to frank
disorientation as this one did. The patient monitors his
end-tidal CO2 at home and his urinary pH. He reports that
when his end-tidal CO2 is low or his pH is not sufficiently
alkalemic he tends to get these episodes.
The only treatment that seems to have helped his symptoms
consistently is bicarbonate replacement.

On consultation with his sleep physician [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) **] it
was decided that given his uncharacterized syndrome he would
be admitted to the MICU for intensive monitoring of his blood
gas and chemistries to further define the biochemical nature of
his syndrome. This originally was to have occurred next week.
He however had another episode of his hypocapneic syndrome
yesterday while vacationing in [**State 108**]. He was disoriented for
two hours. Home test of end-tidal CO2 during a hyperventilation DISEASE
episode was in the 20's. His wife [**Name (NI) 653**] Dr. [**First Name (STitle) **] 6 hours
prior to admission and it was decided he should fly back to
[**Location (un) 86**] and present to the ED for admission to the MICU.

In the ED initial vital signs T 99.7 P 94 BP 111/67 O2 97 on
2L. He was nauseated but no longer disoriented. He had taken
bicarbonate last about 8 hours previously. A VBG revealed
7.41/25/147/16. Bicarb was on chemistries which were otherwise
unremarkable He received zofran for nausea DISEASE as well as one liter
IVF.

On presentation to MICU the patient reports his still feels his
usual symptoms of nausea headache DISEASE and lightheadedness. He
denies fevers DISEASE or sick contacts. [**Name (NI) **] traveled to [**State 108**] last
week and does report his symptoms worsen with altitude or with
air travel.

Past Medical History:
1) Central sleep apnea
2) Coronary artery disease DISEASE single vessel disease DISEASE on [**2116**]
catheterization: two bare metal stents to the OM2 vessel
3) Hypertension DISEASE on antihypertensive medications x 6yrs
4) hyperlipidemia DISEASE
5) Orthostasis postural hypotension DISEASE
6) Gout DISEASE
7) Hypogonadotropic hypogonadism DISEASE
8) Empty sella nl pituitary function
9) Chronic kidney disease DISEASE stage III baseline cr 1.1-1.3
10) Rapid cycling mood disorder DISEASE

Social History:
He is married with two children. There is no history of
tobacco alcohol or illicit drug use. He is a venture
capitalist and engineer.

Family History:
Mother died at age 72 with a neuromuscular disorder dystonia DISEASE
and respiratory failure DISEASE . She also suffered from hypertension DISEASE
and obstructive sleep apnea DISEASE .
His father died at age 64 from stomach cancer DISEASE but had also been
diagnosed with stage I renal cell carcinoma DISEASE and had a CVA DISEASE at age
59. Multiple family members with neurologic difficulties DISEASE .

Physical Exam:
T 99.1Admission Date: [**2194-6-18**] Discharge Date: [**2194-6-29**]

Date of Birth: [**2126-4-22**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Codeine / Tylenol

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea DISEASE on exertion and chest tightness DISEASE

Major Surgical or Invasive Procedure:
[**2194-6-23**]
redo sternotomy/Aortic Valve Replacement with #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue
valve


History of Present Illness:
68 year old male with PMH significant for type 2 DM HTN DISEASE High
cholesterol CAD and BPH who presented to an outside hospital
c/o SOb DOE and chest tightness DISEASE . Pt also had leg edema-. Work
up showed that pt had severe aortic valve stenosis DISEASE .


Past Medical History:
Past Medical History
Aortic Stenosis
type 2 Diabetes Mellitus DISEASE
Hypertension DISEASE
High cholesterol
Coronary Artery Disease DISEASE
Benign Prostatic Hypertrophy-retention after surgery
Past Surgical History
Coronary Bypass Grafting 15 yrs ago at BIs
cholesystectomy
Rt shoulder rotator cuff
tonsillectomy
left index finger surgery
left ring finger trigger surgery
eye surgery


Social History:
Occupation:retired bus driver
Cigarettes: Smoked no [] yes [x] last cigarette 20 years ago
Other Tobacco use:none
ETOH: Admission Date: [**2182-2-3**] Discharge Date: [**2182-2-9**]


Service:

HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female with a history of critical AS paroxysmal atrial
fibrillation hypertension tachy-brady syndrome DISEASE who
presented to the Emergency Room with chest pain DISEASE . In the ED
the blood pressure was noted to be elevated at 230-270
systolic. The patient was given sublingual nitroglycerin
hydralazine and subsequently her blood pressure decreased
into the 80s. The patient was then noted to have ST segments
in V4 through V6 and substernal chest pain DISEASE started after
eating. The patient reports that the chest pain DISEASE was [**10-13**]
squeezing sensation. .................... The patient
reports an episode of similar pain DISEASE months ago. The patient
denied any dyspnea DISEASE on exertion however she does report
lightheadedness. In the ED the patient was subsequently
started on Neo-Synephrine.

PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation DISEASE .
2. SVT tachy-brady DISEASE syndrome.
3. Hypertension DISEASE .
4. AS with valve area 0.7 cm squared.
5. Arthritis.
6. TR 2Admission Date: [**2119-9-19**] Discharge Date: [**2119-9-28**]

Date of Birth: [**2053-4-8**] Sex: M

Service: CARDTHOR

HISTORY OF PRESENT ILLNESS: This is a 63 year old gentleman
with known coronary artery disease DISEASE who is status post
multiple percutaneous transluminal coronary angioplasties and
stents with brachy therapy to his right coronary artery who
was admitted to [**Hospital6 3872**] on [**9-14**] after
three to four hours of chest pain DISEASE and pressure. The patient
ruled out for a myocardial infarction DISEASE . The patient underwent
repeat cardiac catheterization which showed a 40 or 50% left
main lesion 70% left anterior descending lesion 50% ramus
lesion and a 30% right coronary artery lesion. The patient
was transferred to [**Hospital1 69**] for
operative treatment.

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE .
2. Status post percutaneous transluminal coronary
angioplasty and stent to right coronary artery.
3. Hypertension DISEASE .
4. Hypercholesterolemia DISEASE .
5. Diabetes mellitus DISEASE diet controlled.
6. History of colon cancer DISEASE status post sigmoid resection in
[**2104**].

ALLERGIES: No known drug allergies DISEASE .

PREOPERATIVE MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o. q. day.
2. Protonix 40 mg p.o. q. day.
3. Plavix 75 mg p.o. q. day.
4. Hyzaar 100/25 one tablet p.o. q. day.
5. Zocor 20 mg p.o. q. day.
6. Nitropaste one half inch q. four hours.
7. Clonidine patch 0.1 q. Friday.

REVIEW OF SYSTEMS: The patient denied cerebrovascular
accident GI bleedAdmission Date: [**2133-9-3**] Discharge Date: [**2133-9-6**]

Date of Birth: [**2051-5-31**] Sex: M

Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
fever DISEASE


Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
82y/o Cambodian-speaking man with DM HTN presents with one day
of subjective fever DISEASE and night sweats. Pt reports single episode
of nausea DISEASE with a little vomit DISEASE last night with no identifiable
triggers. ROS positive for black stools and cough DISEASE of 1 mo. Of
note pt had a cystoscopy on [**8-27**]. Denies weight changes HA
cp sob abd pain DISEASE focal neurol deficits abnormal bowel DISEASE
movements hematochezia DISEASE .

In the ED initial vital signs were 98.6 85 109/64 (baseline
sbp 150's) RR 16 SAT 100%. Exam was notable for guaic Admission Date: [**2178-5-28**] Discharge Date: [**2178-6-3**]

Date of Birth: [**2114-2-8**] Sex: M

Service: MED

Allergies DISEASE :
Doxepin / Levofloxacin / Oxycontin

Attending:[**First Name3 (LF) 242**]
Chief Complaint:
SOB x 2d

Major Surgical or Invasive Procedure:
none


History of Present Illness:
64 yo M w/ PMHx as below presented to ED on [**5-29**] w/ hypercarbic DISEASE
respiratory failure DISEASE (initial ABG [**5-28**]: 7/29/92/Admission Date: [**2159-3-29**] Discharge Date: [**2159-4-2**]


Service: MEDICINE

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
hypoglycemia DISEASE

Major Surgical or Invasive Procedure:
none.

History of Present Illness:
Ms [**Known lastname **] is an 88 year old Cantonese-dialect speaking female who
presents from [**Hospital6 1643**] Center (nursing home) for
hypoglycemia DISEASE .

Around noon on day of admission staff at her nursing home
noticed she had become less responsive and was unable to move
her extremities. Finger stick was 96. She had just been
administered SC heparin for DVT DISEASE prophylaxis. Given concern for
a stroke DISEASE paramedics were called. When they arrived her
glucose was apparently low and glucagon was administered. An IO
was placed in the left leg and an amp of D50 was administered.
She was brought to the ED where blood sugar was noted to be 16.
She received another amp of D50. Glucose improved transiently
but again came down to 40. Intravenous dextrose (D10W) was
started. She had improvement but several additional
hypoglycemic episodes.

Her white count was noted to be 15000 and a lactate was 4.0.
Her blood pressure remained normotensive. Her temperature was
99.6. She had a CT head and abdomen/pelvis which revealed no
infectious DISEASE focus. She does have ulcers DISEASE of dorsum of both lower
extremities which were treated with keflex 2 weeks priorAdmission Date: [**2195-8-26**] Discharge Date: [**2195-9-11**]

Date of Birth: [**2153-1-25**] Sex: M

Service: NEUROSURG

HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old
gentleman with a past medical history of cerebellar
astrocytoma DISEASE diagnosed in [**2188**] by biopsy. He then followed up
with radiation therapy. The patient was known to have
recurrence of his tumor DISEASE by biopsy on [**2195-5-26**]. He did not
have chemotherapy secondary to infectious DISEASE issues. The
patient was noted to have increased unsteadiness of gait DISEASE per
a clinic note.

The patient came in with a one day headache DISEASE on the left and
vomiting DISEASE times four days. He said that the left side
numbness DISEASE and weakness DISEASE was worse. The patient also had a
history of diabetic complications DISEASE from steroids. He had a
head CT scan on admission which showed a large bleed DISEASE into
the site of the prior tumor DISEASE .

PAST MEDICAL HISTORY: The past medical history included
hepatitis B DISEASE positive PPD positive herpetic keratitis DISEASE
epididymitis DISEASE and piloid astrocytoma DISEASE which was recurrent.

PAST SURGICAL HISTORY: The patient had biopsies times two
the last one being in [**2195-5-26**].

ALLERGIES: The patient had no known drug allergies DISEASE .

PHYSICAL EXAMINATION: On physical examination the patient
had a blood pressure of 140/94 a heart rate of 60 a
respiratory rate of 16 and an oxygen saturation of 100% on
room air. He was awake alert and in no acute distress. The
heart had a regular rate and rhythm with an S1 and S2. The
lungs were clear bilaterally. The abdomen was soft
nontender and nondistended with positive bowel sounds.

Neurologically the pupils were unequal and reactive with the
right being greater than left in size. On the left there
was no lateral gaze. The tongue was midline. The left
finger-to-nose was inaccurate. There was a left facial
droop. The left upper extremity was [**4-30**] and the left lower
extremity was [**4-30**]. The patient had no drift. He was alert
and oriented times three. Speech was fluent. He was
following commands.

RADIOLOGY: A CT scan showed a 3 cm bleed DISEASE with significant
mass effect with an obstructive hydrocephalus DISEASE .

LABORATORY DATA: On admission the patient had a sodium of
140 potassium of 3.7 chloride of 101 bicarbonate of 24
BUN of 12 creatinine of 0.7 and glucose of 161. There was a
white blood cell count of 7000 hematocrit of 44.5 and
platelet count of 294000. Prothrombin time was 13 partial
thromboplastin time was 29 and INR was 1.1.

HOSPITAL COURSE: The patient was admitted to the surgical
intensive care unit. On [**2195-8-26**] the patient went to the
operating room for a left suboccipital craniotomy for
evacuation of hematoma DISEASE and right frontal drain placement
without complications.

The patient continued to be monitored in the surgical
intensive care unit. He was awake alert following commands
and moving all extremities strongly. He did have a left
upper motor neuron seventh nerve palsy which was there prior
to surgery. Vital signs remained stable. The ventricular
drain was pulled out by the patient on [**2195-8-29**] and was
replaced. The patient was extubated on postoperative day #1.

On [**2195-8-31**] the patient became tachypneic requiring
intubation for full respiratory failure DISEASE . On neurological
examination the patient was following commands. He had left
lateral gaze to the midpoint but was unable to go to extreme
lateral gaze on the left. The right eye had slight lateral
gaze deviation. He was following simple commands. He had
decreased strength on the right but improved with no focal
drift. The patient was extubated on [**2195-9-2**] and had a
swallow study which showed that the patient was aspirating
with all consistencies. Therefore the patient was made
n.p.o. and a feeding tube was placed.

A family meeting was held with the family to discuss the
grave prognosis of the patient's condition. The patient was
initially made Admission Date: [**2196-3-17**] Discharge Date: [**2196-3-19**]

Date of Birth: [**2153-1-25**] Sex: M

Service: MICU/[**Location (un) **]

HISTORY OF PRESENT ILLNESS: This is a 43 [**Hospital **] nursing
home resident who is Ethiopian speaking with a history of
recurrent inoperable cerebellar astrocytoma DISEASE with swallowing
dysfunction weight loss DISEASE and subsequent functional decline.
The patient had recently pulled out his J tube was refusing
supplement nutrition. The patient was seen by Dr. [**Last Name (STitle) 724**] who
is his neuro-oncologist two weeks ago and told that he had an
extremely poor prognosis. He was seen by his primary care
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4813**] [**Last Name (NamePattern1) 3501**] one week prior to admission with a
cough DISEASE and reportedly wished to spend the remainder of his
life at home. He is interested in pursuing a hospice. The
evening of admission the patient was alert and responsive
but had refused dinner and his evening medications the
previous night. He was found by a CMA at the nursing home to
be unresponsive at 1:45 a.m. He was transferred to [**Hospital1 1444**] and found to be febrile DISEASE with
a temperature of 104 intubated for airway protection and a
chest x-ray was obtained.

PAST MEDICAL HISTORY: 1. Recurrent inoperable cerebellar
astrocytoma DISEASE diagnosed [**2188-2-26**] treated with x-ray
therapy at [**Hospital6 1708**] on a Decadron taper.
Recurrence noted on brain biopsy by [**2195-5-26**]. He had a
subsequent bleed of [**2195-8-26**] and hydrocephalus DISEASE
craniotomy and shunt but is not a candidate for
chemotherapy. 2. History of aspiration pneumonia DISEASE . 3.
History of positive PPD with a negative chest x-ray in [**2187**]
completed six months of INH prophylaxis. 4. History of
schistosomiasis DISEASE and Strongyloides DISEASE while on Decadron. 5.
Diabetes DISEASE secondary to steroids. 6. History of herpes DISEASE
keratitis DISEASE . 7. Swallowing dysfunction DISEASE status post
percutaneous endoscopic gastrostomy 8. Hepatitis B
positive. 9. History of malaria DISEASE in [**2187**] treated with
Chloroquine.

ALLERGIES: The patient has no known drug allergies DISEASE .

MEDICATIONS ON ADMISSION: 1. Decadron 2 mg po q.i.d. 2.
NPH 6 units q.a.m. and 6 units q.p.m. 3. Regular insulin
sliding scale. 4. Acyclovir 400 mg po b.i.d. 5. Multi
vitamin one po q.d. 6. Colace 100 mg po b.i.d. 7. Pred
Forte ophthalmologic drops OD b.i.d. 8. Polysporin ointment
one drop to OS b.i.d.

SOCIAL HISTORY: The patient came to the US from [**Country 4825**] in
6/93. He is separated from his wife and children. He lived
at [**Hospital 2670**] Nursing Home in [**Location (un) **].

PHYSICAL EXAMINATION ON ADMISSION: Temperature 104 rectally.
Blood pressure 120/70. Heart rate 111. Respiratory rate 20.
O2 sat 97%. He was intubated. His right pupil was deviated
to the right and nonreactive. His left pupil was 3 mm to 2
mm reactive. His neck was soft supple with no
lymphadenopathy DISEASE . Heart was tachycardic with no murmurs. His
chest was clear to auscultation bilaterally. His abdomen was
soft and nontender. He was heme negative on rectal
examination. His extremities were warm and well profuse.
Neurologically he was unresponsive. He was on a ventilator
with settings of IMV of 600 by 12 5 of PEEP 5 of pressure
support and 100% FIO2.

LABORATORY: His white count was 8.4 hematocrit 38.9
platelets 167. Sodium 143 potassium 3.7 chloride 105
bicarb 20 BUN 26 creatinine 1.1 glucose 248. CT 14.2 INR
1.4 PTT 30.8. Sputum had 4Admission Date: [**2165-3-31**] Discharge Date: [**2165-4-13**]


Service: CARDIOTHORACIC

Allergies DISEASE :
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
worsening shortness of breath dyspnea DISEASE on exertion and edema DISEASE

Major Surgical or Invasive Procedure:
s/p AVR(27mmCE pericardial) MV repair
s/p tracheostomy


History of Present Illness:
Mr. [**Known lastname 1662**] has had a long standing murmur had done well until 1
year PTA when he began developing SOB DOE orthopnea DISEASE and pedal
edema DISEASE .

Past Medical History:
1:aortic stenosis
2:mitral regurgitation
3:atrial fibrillation DISEASE
4:s/p DISEASE pacemaker insertion
5:h/o endocarditis DISEASE
6:HTN
7:BPH
8:s/p DISEASE R THR
9:s/p L TKR


Pertinent Results:
[**2165-4-12**] 02:15AM BLOOD WBC-10.5 RBC-3.30* Hgb-9.8* Hct-30.6*
MCV-93 MCH-29.8 MCHC-32.1 RDW-13.4 Plt Ct-234 DISEASE
[**2165-4-12**] 02:15AM BLOOD Plt Ct-234 DISEASE
[**2165-4-12**] 02:15AM BLOOD PT-12.9 PTT-26.6 INR(PT)-1.1
[**2165-4-12**] 02:15AM BLOOD Glucose-110* UreaN-48* Creat-1.2 Na-133
Cl-88* HCO3-40*
[**2165-4-12**] 11:25AM BLOOD Type-ART pO2-81* pCO2-59* pH-7.44
calHCO3-41* Base XS-12 DISEASE

Brief Hospital Course:
Mr. [**Known lastname 1662**] was admitted to [**Hospital1 18**] [**3-31**] for pre operative
anticoagulation. He was taken to the operating room on [**4-2**]
with Dr. [**Last Name (STitle) **] for an AVR/MV repair. He tolerated the
procedure well and was transferred to the ICU. He was weaned
and extubated from mechanical ventilation on POD#1. He became
oliguric DISEASE despite adequate cardiac output and normal creatinine.
He was started on dopamine and Natrecor. He was also noted to
have worsening oxygenation and increased work of breathing. He
was started on BiPAP with good results. He underwent a renal
ultrasound which showed no hydronephrosis DISEASE . He was given
aggressive diuretic DISEASE therapy which resulted in adequate urine
output. His creatinine only minimally rose to 1.3 and he
gradually required only minimal diuretics for adequate urine
output. His respiratory status continued to be problem[**Name (NI) 115**] and
he required BiPAP for several days. An ENT consult was obtained
to rule out upper airway edema DISEASE . A bedside fiberoptic exam
showed an very large uvula and no airway edema DISEASE . It was thought
that the uvula was causing airway obstruction DISEASE worsened by fluid
overload DISEASE and the decision was made to place a tracheostomy. He
underwent tracheostomy on [**4-9**] with a #8 per fit trach placed
without difficulty. He was weaned from the ventilator over the
next day and was placed on trach mask with Passey Muir valve on
[**4-11**]. An attempt to rest the patient on the ventilator made him
uncomfortable and he requested to not be put back on. His
arterial blood gasses showed adequate oxygenation and balanced
acid base status. He was started on Coumadin after his
tracheostomy for his atrial fibrillation DISEASE and is cleared for
discharge to rehab on [**4-12**]

Medications on Admission:
coumadin
hytrin 2mg po qd
lasix 80mg po qd
MVI
folate


Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain DISEASE .
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature Admission Date: [**2158-6-16**] Discharge Date: [**2158-6-19**]

Date of Birth: [**2103-3-15**] Sex: F

Service:


ADMISSION DIAGNOSIS: Right flank pain DISEASE .

HISTORY OF PRESENT ILLNESS: The patient is a 55 year-old
male status post kidney transplant in [**2149**] history of
hypertension dyspnea diabetes anemia DISEASE who has been having
some abdominal pain DISEASE . The patient had recently been discharged
from the [**Hospital1 69**] on [**2158-5-1**]
with similar complaints on the medicine service. A transverse
right upper quadrant pain DISEASE radiating to the back and shoulder
8 out of 10. Patient is status post renal transplant [**Numeric Identifier 4837**]
and has been off dialysis ever since the surgery. The patient
was well until three days ago when sharp right upper quadrant
pain DISEASE who has not been able to tolerate anything by mouth.
Patient has chronic constipation DISEASE no diarrhea DISEASE . Last bowel DISEASE
movement was on [**2158-6-14**]. The pain DISEASE has progressive
become more persistent and is associated with low grade
fevers DISEASE of 99. Patient denies shortness of [**Year (4 digits DISEASE ) 1440**] chest pain DISEASE
hematuria dysuria DISEASE no dark urine or [**Male First Name (un) 1658**] colored stools. On
last admission the patient had a work up all of which was
negative including ultrasound HIDA scan abdominal CT and CT
of chest.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE .
2. Diabetes.
3. Status post renal transplant in [**2149**].
4. Sciatica.
5. Multinodular goiter DISEASE .
6. Cataract surgery.
7. Hyperlipidemia.
8. Depression.
9. History of shoulder pain DISEASE .
10. History of vertigo DISEASE .
11. History of nephrolithiasis DISEASE .

MEDICATIONS ON ADMISSION: Neural 100 in the morning 50 in
the afternoon. Diltiazem 240 mg q day CellCept [**Pager number **] b.i.d.
Lipitor 5 mg q day prednisone 10 mg 10 mg q.o.d. lisinopril
5 to 10 mg q day Lasix 60 q day Ativan q.A.M. aspirin 81
mg q day lactulose q.o.d. Lantus 30 units q.P.M. sliding
scale.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: No tobacco no alcohol no drugs.

FAMILY HISTORY: Noncontributory.

LABORATORIES ON ADMISSION: WBC 7.0 hematocrit 29.6
platelets 264 sodium 138 5.3 104 22 BUN/creatinine
51/1.5 with glucose 174. Ultrasound was obtained [**2158-6-15**] demonstrating distended gallbladder without evidence of
cholecystitis DISEASE . No evidence of intrahepatic or extrahepatic biliary duct dilatation DISEASE . Patient also had a CT of the abdomen
and pelvis on [**2158-6-15**] demonstrating 1) distended
gallbladder with no gallstones DISEASE divide or evidence of acute
cholecystitis DISEASE . There is no intra or extrahepatic biliary duct
dilatation. 2) Stable appearance of the shunts of the
transplant kidney with unchanged appearance of perinephric DISEASE
stranding around the transplant kidney. 3) There is no
evidence of acute pathology to explain the patient's pain DISEASE .

HOSPITAL COURSE: Patient was admitted to Dr.[**Name DISEASE (NI) 4838**]
service. Gastroenterology was consulted and it was suggested
for patient to have an upper endoscopy. Nephrology was
consulted. Urine blood and sputum were obtained which were
all unremarkable. On [**2158-6-19**] patient had endoscopy
demonstrating normal esophagus normal stomach normal
duodenum normal upper endoscopy to second portion of the
duodenum. Patient felt better and on [**2158-6-19**] patient
was discharged to home.

Patient was discharged on the following medications: Neural
100 mg 100 mg p.o. q.A.M. and Neural 50 mg q. P.M. diltiazem
240 mg 1 p.o. q day atorvastatin calcium 25 mg q day Lasix
60 mg q day aspirin 81 mg q day lactulose p.r.n. MMF 500
mg b.i.d. prednisone 10 mg q.o.d. Dilaudid 2 mg 1 to 2 p.o.
q 6 hours p.r.n.

Patient to follow up with nephrology by calling [**Telephone/Fax (1) 673**]
for an appointment. Also follow up with Dr. [**First Name8 (NamePattern2) 110**] [**Last Name (NamePattern1) 656**] [**Telephone/Fax (1) 4839**]. Another appointment is with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2158-6-21**] at 9 A.M. and also with physical therapy which was
scheduled on [**2158-6-20**] at 2:30 P.M. at 1[**Location (un) 4840**]in [**Location (un) **] [**State 350**]. Patient should call
transplant surgery immediately at [**Telephone/Fax (1) 673**] if any fevers DISEASE
chills nausea vomiting abdominal pain hesitancy DISEASE in
urinary shortness DISEASE of [**Last Name (LF) 1440**] [**First Name3 (LF) 691**] sustained right upper
quadrant or an increase in lower extremity edema.

FINAL DIAGNOSIS: Probable costochondritis.

SECONDARY DIAGNOSIS: Status post renal transplant.



[**Name6 (MD) **] [**Name8 (MD) **] [**MD Number(1) 4841**]

Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2158-9-28**] 10:38:33
T: [**2158-9-28**] 11:42:00
Job#: [**Job Number 4842**]

Admission Date: [**2162-6-8**] Discharge Date: [**2162-6-18**]

Date of Birth: [**2103-3-15**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4854**]
Chief Complaint:
Shortness of [**First Name3 (LF) 1440**] Major Surgical or Invasive Procedure DISEASE :
Bipap


History of Present Illness:
59 year old female with type 1 diabetes hypertension DISEASE frequent
UTI DISEASE on tetracycline immunosuppresion ESRD DISEASE s/p CRT in [**2149**] who
presents with acute onset of dyspnea DISEASE .
.
The patient was recently admitted from [**Date range (1) 4859**]/09 for
pyelonephritis DISEASE and e. coli bacteremia DISEASE . She presented with
weakness DISEASE and fever DISEASE . She was on Zosyn and ciprofloxacin until
sensitivies returned and then switched to oral ciprofloxacin.
She was on tetracycline for UTI DISEASE suppression by her ID MD Dr.
[**Last Name (STitle) 724**]. She was discharged with 2 week course of ciprofloxacin.
Also Cr elevated and felt to be prerenal DISEASE secondary to
bacteremia DISEASE but also with some component of ATN DISEASE which resolved
with IVFs. Diuretics slowly restarted upon discharge.
.
The patient went to her appointment with her NP this morning.
Today her wt was noted to be up 28 lbs from [**2162-5-20**]. The plan
was to increase lasix from 80 mg [**Hospital1 **] to 120 mg qAM and 80 mg QPM
and to follow up with Dr. [**Last Name (STitle) 1366**] on [**6-11**]. After her
appointment she went home and around noon while walking she
felt acute onset of dyspnea DISEASE . She notes increased wt gain DISEASE since
her recent discharge from [**Hospital1 18**] on [**6-1**] but notes that she is
on increased doses of her lasix. She also denies any medication
noncompliance. Denies dietary indiscretions DISEASE but has been
eating only chicken soup which her daughters prepare for her (1
tsp salt in each batch). She also drinks 2 glasses of cranberry juice cup of coffee and cup of tea. She also has been eating
many low salt saltine crackers and ginger ale per her daughter.
[**Name (NI) **] daughter visited her the night prior to discharge and noted
that her mom wsa tired and weak but not SOB. Today though the
patient called her daughter and complained of Admission Date: [**2162-8-8**] Discharge Date: [**2162-8-12**]

Date of Birth: [**2103-3-15**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Tetracycline

Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Epigastric Pain DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 59 year old woman with history of HTN DM DISEASE s/p renal
transplant in [**2150**] currently on cellcept and cyclosporine
presents with one week of nausea DISEASE and vomiting DISEASE .

One week prior to presentation she has acute onset of nausea DISEASE
vomiting DISEASE and abd pain DISEASE . She did not notice any blood in the
vomitus. Her pain DISEASE was [**8-2**] epigastric and radiated to the back.
She has not had pain DISEASE like this before. She denies drinking
alcohol. No recent spider bites. No change in her weight
recently. No personal or family history of cancer DISEASE .

She was recently admitted at [**Hospital1 **] for dyspnea DISEASE attributed to
pulmonary edema/fluid overload DISEASE . ECHO [**6-1**] shows mild LVH DISEASE and EF
55%. Prior to this she was admited for E. coli pyelonephritis DISEASE
and was treated with Zosyn and ciprofloxacin.

She has history of ESRD DISEASE s/p cadaveric renal transplant in [**2150**].
She has a baseline cre of 2.5 (near her baseline). She has been
mantained on immunosupression with prednisone cellcept and
cyclosporin (all of these were started more than one year ago
without recent changes). She also takes EPO for anemia DISEASE .
.
In the ED initial vs were: 97.4 63 160/63 18 99. Patient was
placed NPO and given morphine for pain DISEASE and ondasentron. RUQ US
showed a distened GB but without stones. No CBD dilatation. CXR
without acute changes. While in the ED her urine output was 150
cc over a period of 5 hrs. She received 1 lt NS. Prior to
transfer her vitals were 97.6 60 149/44 18 99RA.
.
Review of sytems:
(Admission Date: [**2158-1-31**] Discharge Date: [**2158-2-4**]

Date of Birth: [**2111-2-7**] Sex: F

Service:
ADMITTING DIAGNOSIS: Pelvic mass.

POSTOPERATIVE DIAGNOSIS: Ovarian cancer DISEASE .

HISTORY OF THE PRESENT ILLNESS: The patient was admitted for
with symptoms of bloating DISEASE . The patient's workup revealed a
large pelvic mass DISEASE that was suspicious for ovarian cancer DISEASE .

PAST MEDICAL HISTORY: Significant for migraines DISEASE .

PAST SURGICAL HISTORY: Noncontributory.


PAST OBSTETRICAL HISTORY: Noncontributory.

HOSPITAL COURSE: The patient was admitted for an exploratory
laparotomy TAH/BSO peritoneal washings omentectomy and
debulking and pelvic lymph node dissection. The estimated
blood loss DISEASE of the procedure was 250 cc. The procedure was
uncomplicated. The patient's
postoperative course was complicated by an episode of
respiratory arrest DISEASE believed to be related to narcotic
sensitivity. The patient had received in total 3 mg of
morphine IV and 4 mg of Dilaudid IV and then 4 mg of Dilaudid DISEASE
subcutaneously. A code was called. The patient's airway was
immediately secured and she was immediately bagged. Narcan
was given IV and the patient responded well with a vigorous
respiratory effort.

The patient was transferred to the MICU for closer monitoring
and at that time was started on a Narcan DISEASE drip. The patient
did well for the remainder of the night and the Narcan drip
was then discontinued in the early morning. The patient's
pain DISEASE control overnight was managed with a dose of p.o.
Percocet early in the morning.

The patient was called out of the MICU on postoperative day
number one and transferred to the regular Postsurgical Floor DISEASE .
The patient's pain DISEASE control was initially controlled with
Percocet and then transitioned to Toradol and then finally
after a consultation with the Pain DISEASE Service was transitioned
to Flexeril 10 mg t.i.d. and Motrin 600 mg q. six hours. In
addition Physical Therapy consult was obtained to provide
assistance with the patient in ambulation and mobility.

The patient's urine output was adequate throughout her
hospitalization/postoperative DISEASE course. She began tolerating
p.o. on postoperative day number one. On postoperative day
number one she also began ambulating. The patient's Foley
was discontinued and she was voiding spontaneously. Her
vital signs remained stable for the remainder of the
hospitalization. Her abdominal examination had positive
bowel sounds and was appropriately tender. Her incision
remained clean dry DISEASE and intact. The patient will be
discharged to home on a full diet with Flexeril 10 mg t.i.d.
and 600 mg of Motrin q. six hours simethicone 80 mg q. eight
hours.

DISPOSITION: The patient will be discharged to home.

CONDITION ON DISCHARGE: Good. The patient will have home
VNA to assess her postoperative course.

FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) 1022**] in
approximately one months time.




[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] M.D. [**MD Number(1) 4871**]

Dictated By:[**Name8 (MD) 4872**]

MEDQUIST36

D: [**2158-2-4**] 01:04
T: [**2158-2-6**] 12:56
JOB#: [**Job Number 4873**]





Admission Date: [**2128-2-9**] Discharge Date: [**2128-2-26**] Service: CARDIOTHORACIC SURGERY

CHIEF COMPLAINT: A 78-year-old man transferred from [**Hospital6 4874**] status post myocardial infarction DISEASE
transferred to [**Hospital1 69**] for
cardiac catheterization.

HISTORY OF PRESENT ILLNESS: A 78-year-old man with past
medical history significant for PMR hypertension with no
known history of coronary artery disease DISEASE who presented at
outside hospital complaining of chest pressure radiating to
neck when using a snow-blower. Pain subsided with rest but
returned with activity.

He says three days ago he had the same symptoms when also
using a snow-blower. No dyspnea palpitations nausea DISEASE or
vomiting DISEASE at the time of chest pressure. Reports waking up
with chest pain DISEASE approximately one week ago. Had jaw pain DISEASE at
that time also. Also reports that over the past month he has
had increasing chest pain DISEASE with exertion. Daughter who is a
R.N states that he has had increased dyspnea DISEASE with exertion
x1 year.

The patient was treated with Lopressor and started on Heparin
and Aggrastat at [**Hospital6 4620**]. First set of
enzymes showed a CK of 162 MB are not available and
troponin of 40.6. He is currently pain DISEASE free.

PAST MEDICAL HISTORY:
1. PMI x10 years on prednisone.
2. Hypertension DISEASE .
3. Gastroesophageal reflux disease DISEASE .
4. Hiatal hernia DISEASE .
5. Pernicious anemia DISEASE .
6. Cholecystectomy.

SOCIAL HISTORY: Smokes [**5-8**] cigars per day x40 years but no
alcohol use none since [**2102**]. Retired [**Location (un) 86**] police officer.
Lives with his wife in [**Name (NI) 1411**].

FAMILY HISTORY: Both parents died of strokes DISEASE in their 90s.

MEDICATIONS AT HOME:
1. Zantac 100 mg [**Hospital1 **].
2. Norvasc no dose.
3. Vioxx no dose.
4. Prednisone 20 mg q day.
5. Neurontin 100 mg q day.
6. Flomax 0.4 mg q day.
7. Tums no dose.

ALLERGIES: Penicillin which causes a rash DISEASE .

PHYSICAL EXAM DISEASE AT TIME OF ADMISSION: Heart rate 77 blood
pressure 151/93 respiratory rate 20 and O2 sat is 98% on 2
liters. General: Pleasant-elderly man well appearing in no
acute distress. HEENT: Pupils 1.5 mm. Oropharynx is moist.
Lungs are clear to auscultation bilaterally with marked
diminished breath sounds throughout. Heart: Regular rate
and rhythm normal S1 S2 with no murmur. Abdomen is soft
nontender nondistended with positive bowel sounds DISEASE .
Extremities with 2Admission Date: [**2129-7-19**] Discharge Date: [**2129-8-21**]


Service: [**Doctor First Name 147**]

Allergies DISEASE :
Penicillins

Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Carcinoma DISEASE in situ and high grade dyplasia of the distal stomach Major Surgical DISEASE or Invasive Procedure:
1. subtotal gastrectomy with roux en y reconstruction repair of
hiatal hernia DISEASE and fundoplication [**2129-7-19**]
2. Exploratory laparotomy drainage of the abdomen small bowel
resection with anastamosis placement of temporary mesh closure
[**7-21**].
3. Laparotomy closure of abdominal wall [**2129-7-25**]

History of Present Illness:
79 yo M with a 10 yr h/o GERD underwent an EGD in [**3-9**] which
showed patchy lesions in the stomach. Biopsies revealed
metaplasia and suspicion gor early gastric carcinoma DISEASE .

Past Medical History:
CAD sp CABG X 4 MVR
GERD
polymyalgia rheumatica DISEASE X 14 yrs on steriods
h/o gallstone pancreatitis DISEASE
sp cholecystectomy [**13**]'
prostate cancer DISEASE sp radiation in 94'

Physical Exam:
NAD
RRR
CTAB
well healed median sternotomy
soft NT
well healed R subcostal incision
No E/C/C
Neuro grossly intact

Pertinent Results:
[**2129-8-21**] 01:25AM BLOOD WBC-18.3* RBC-3.37* Hgb-10.0* Hct-29.4*
MCV-87 MCH-29.8 MCHC-34.2 RDW-17.3* Plt Ct-57*
[**2129-7-30**] 04:57PM BLOOD WBC-21.7* RBC-3.11* Hgb-9.3* Hct-28.4*
MCV-91 MCH-29.8 MCHC-32.6 RDW-17.4* Plt Ct-78*
[**2129-7-30**] 03:30AM BLOOD WBC-31.7* RBC-3.48* Hgb-10.0* Hct-33.5*
MCV-96 MCH-28.6 MCHC-29.7* RDW-17.3* Plt Ct-86*
[**2129-7-28**] 02:19AM BLOOD WBC-33.3* RBC-3.84* Hgb-10.9* Hct-36.4*
MCV-95 MCH-28.4 MCHC-30.0* RDW-16.5* Plt Ct-66*
[**2129-7-26**] 03:00AM BLOOD WBC-25.6* RBC-3.78* Hgb-11.5* Hct-34.3*
MCV-91 MCH-30.4 MCHC-33.6 RDW-16.2* Plt Ct-50 DISEASE *
[**2129-7-22**] 12:51PM BLOOD WBC-13.3*# RBC-4.20* Hgb-12.6* Hct-38.6*
MCV-92 MCH-29.9 MCHC-32.5 RDW-16.1* Plt Ct-110*
[**2129-7-21**] 11:39PM BLOOD WBC-6.5 RBC-4.01* Hgb-12.1* Hct-35.6*
MCV-89 MCH-30.1 MCHC-33.9 RDW-15.6* Plt Ct-127*
[**2129-7-21**] 07:40AM BLOOD WBC-1.5*# RBC-2.96* Hgb-8.5* Hct-27.3*
MCV-92 MCH-28.8 MCHC-31.2 RDW-15.9* Plt Ct-222
[**2129-7-19**] 01:04PM BLOOD WBC-11.5* RBC-3.64* Hgb-10.6* Hct-30.9*
MCV-85 MCH-29.0 MCHC-34.1 RDW-15.5 Plt Ct-220
[**2129-8-9**] 01:05PM BLOOD Neuts-48* Bands-32* Lymphs-15* Monos-3
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 NRBC-4* Plasma-1*
[**2129-8-21**] 01:25AM BLOOD Plt Ct-57*
[**2129-8-20**] 02:02AM BLOOD Plt Ct-20*
[**2129-8-17**] 07:30PM BLOOD Plt Ct-84*#
[**2129-8-14**] 02:03AM BLOOD Plt Ct-20*
[**2129-8-11**] 02:59AM BLOOD Plt Smr-RARE Plt Ct-18* LPlt-3Admission Date: [**2178-11-15**] Discharge Date: [**2178-12-2**]

Date of Birth: [**2114-2-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Doxepin / Levofloxacin / Oxycontin

Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Respiratory Failure DISEASE

Major Surgical or Invasive Procedure:
Tracheostomy Placement
[**First Name3 (LF) 282**] tube placement

History of Present Illness:
64 yo man with h/o lung CA s/p R pneumonectomy COPD DISEASE mini-trach
to manage secretions on home O2 who presents c/o 4 days
progressively worsening SOB. Need to increase home O2 from 2 to
3 liters. In ED ABG 7.39/62/163 on 2L NC (which is basically his
baseline). Given combivent solumedrol clinda and azithro for
presumed COPD DISEASE exacerbation. Initially admitted to MICU for close
monitoring started on Azithromycin and CTX switched to Ceftaz
given past history of Pseudomonas. Transferred to floor on
[**11-17**] stable and at baseline. On floor patient had repeated
episodes of desaturation DISEASE with tachypnea DISEASE . Became SOB on [**11-18**] in
AM given Ativan 1 Morphine 2 and Valium 5 with some initial
improvement. Then found to be lethargic and ABG with PCO2 102
pH 7.22. Brought to the ICU for further management.

Past Medical History:
Lung carcinoma DISEASE status post right pneumonectomy.
Prostate cancer DISEASE status post resection.
History of perioperative PE on anticoagulation.
Atrial fibrillation DISEASE on anticoagulation.
Hypertension DISEASE .
Diabetes type II DISEASE .
Obstructive sleep apnea DISEASE .
Hypercholesterolemia DISEASE .
B12 deficiency DISEASE .
Cataracts DISEASE

Social History:
He lives with his wife. [**Name (NI) **] has a 3-pack-per-day tobacco history
but quit in [**2174**] and an overall 160-pack-per-year history. No
recent history of alcohol use.

Family History:
Mother with coronary artery disease DISEASE .


Physical Exam:
Upon Discharge:
Gen: Alert NAD cooperative well appearing
HEENT: PERRLA [**Year (4 digits) **] MMM/clear trach in place
CV: irreg rhythym reg rate no m/r/JVD
Pulm: coarse BS on the left transmitted BS on R
Ab: s/nd/[**Last Name (LF) **] [**First Name3 (LF) 282**] in place
Ext: no LE edema DISEASE 2Admission Date: [**2105-6-21**] Discharge Date: [**2105-6-23**]

Date of Birth: [**2032-9-11**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Fever cough tachycardia DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 4882**] is a 72 y.o. M with Stage III CKD DISEASE likely from
hypertension DISEASE followed by Dr. [**Last Name (STitle) 4883**] hypertension DISEASE and gout DISEASE
who presents with 5 days of cough fever DISEASE and malaise. The
patient reports that he has not been feeling well since Tuesday.
He felt like he needed to see the doctor but put this off. He
has been drinking [**12-26**] water bottles a day but not eating as
nothing tastes good. He endorses subjective fever DISEASE for last 5
days as he felt hot. He also has had a productive cough DISEASE of white
sputum that is new. He also endorsed feeling lightheaded with
standing but no dizziness DISEASE .
He has been drinking 1 L of [**First Name5 (NamePattern1) 4884**] [**Last Name (NamePattern1) 4885**] Black every 2 days
with last drink on Monday. He called his neighbor as he
continued to feel unwell today and he was brought in by
neighbor. Admission Date: [**2143-1-21**] Discharge Date: [**2143-2-5**]

Date of Birth: [**2090-5-26**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Nafcillin / cefazolin

Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
acute epidural abscess MSSA bacteremia DISEASE

Major Surgical or Invasive Procedure:
1. Total laminectomy of L1 L2 L3 L4 and L5.
2. Incision and drainage.
3. Debridement.


History of Present Illness:
Mr. [**Known lastname **] is a 52-year-old male with medical history
significant for gout DISEASE involving the left ankle for 8 years
atrial fibrillation DISEASE on warfarin Hypertension Hyperlipidemia
and gout DISEASE who presented in atrial fibrillation DISEASE with rapid
ventricular response on [**2143-1-18**] and was later found to have
MSSA bacteremia DISEASE . During the admission he required Medical ICU
monitoring for neurochecks and further evaluation of epidural
abscess.

Pt initially presented to his PCP with an erythematous painful
left ankle with concern for gout DISEASE flare. When seen by his PCP
[**Name10 (NameIs) **] was SOB and found to be in afib with rapid ventricular
response. He was transferred to the [**Hospital3 2568**] ED where the
patient was evaluated by orthopedics who felt that the patient
had a painful left ankle with somewhat preserved passive range
of motion and that his exam could be consistent with cellulitis DISEASE
of the lateral aspect of the ankle. Initial labs showed INR of
7.4 Lactic acid of 1 WBC 18 BUN and creatinine of 44 and 0.8
AST and ALT of 108 and 127 respectively Alkaline Phos 297 and
C-reactive of 348. He was started on Ampicillin/sulbactam for
antimicrobial coverage for possible cellulitis DISEASE overlying gout DISEASE .
However on the night of [**1-18**] he spiked to 102.3 and prelim
cultures grew GPC's and Vancomycin was added. He had x-rays of
the left ankle that showed no acute fracture DISEASE and LENI was
negative for DVT DISEASE . CTA was done at that time which showed no PE
but showed pulmonary nodules.

Subsequently blood cultures in [**12-29**] bottles grew out MSSA
bacteria and she was switched to oxacillin 2g IV q4hrs. TTE was
done which was poor quality but showed no vegetations DISEASE . For his
Afib DISEASE he was treated with IV diltiazem and subsequently
switched to IV and then po dilt. Imaging done at that time was
concerning for an epidural collection and possibly abcess DISEASE in the
L2 L3 and L4 level. The provisional report was reported by Dr.
[**Last Name (STitle) 4892**] radiologist at [**Hospital1 18**]. The patient was evaluated by the
Neurosurgeon Dr. [**First Name (STitle) **] [**Name (STitle) 3704**] who recommended that the
patient be transfered the patient to [**Hospital1 18**] as the patient
requires more MRI of the Spine (Thoracic and Cervical) and a MRI
brain to rule out any more extensive pathology.

On arrival to the MICU the patient was somnolent but
arousable. He has diffuse wheezing DISEASE bilaterally. He endorses back
pain DISEASE and neck pain DISEASE . His vital signs are HR 111 BP 103/72 O2 96%
2L.

The patient was subsequently stabilized in the medical ICU and
later transferred to the hospital medicine service.

Review of systems:
(Admission Date: [**2125-8-16**] Discharge Date: [**2125-8-24**]

Date of Birth: [**2061-8-29**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest burning DISEASE

Major Surgical or Invasive Procedure:
[**2125-8-20**] CABG x 5 (LIMA to LAD SVG to Ramus SVG to OM1 and OM2
sequentially SVG to PDA)


History of Present Illness:
63 year old white male with no previous cardiac history who
developed chest burning DISEASE on exertion while on vacation.
Cardiology workup revealed non-ST elevation MI. Cardiac
catheterization and coronary angiography reveals severe 3VD.


Past Medical History:
Coronary artery disease DISEASE
NSTEMI [**2125-8-1**]
infrarenal AAA
prostate cancer DISEASE s/p seed implants [**2121**]
melanoma- anterior abd wall- awaiting excision


Social History:
Manufacturer of stair cases. Lives with wife. Quit smoking 40
years ago with 12 pyh

Family History:
No family history of coronary disease DISEASE .

Physical Exam:
Pulse: 73 Resp: 14 O2 sat: 95%RA
B/P Right: 149/100 Left:
Height: 68Admission Date: [**2129-3-9**] Discharge Date: [**2129-3-17**]

Date of Birth: [**2082-11-14**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Bactrim DS

Attending:[**Doctor First Name 3298**]
Chief Complaint:
pain DISEASE crisis

Major Surgical or Invasive Procedure:
right internal jugular central venous catheter placement


History of Present Illness:
46 yo F with sickle cell anemia DISEASE multiple admission for pain DISEASE
crises who presented with an acute onset bilateral knee
shoulder hip and chest pain DISEASE consistent with prior pain DISEASE
crises.

The patient experienced the acute onset of knee pain DISEASE the morning
of her admission while brushing her teeth about 20 minutes
after getting up. This was followed by chest shouler DISEASE and hip
pain DISEASE bilaterally. Given the severe pain DISEASE the patient presented
to the emergency room.

In the ED initial vital signs were 98.2 95 133/81 20 100%
4L/NC. The patient was given normal saline 1 liter and dilaudid
1 mg IV x 3.

There was concern that she was developing acute chest and she
was admitted to the MICU. She complained of significant pain DISEASE
when she arrived the the ICU.

Past Medical History:
1) Sickle Cell Disease- Hgb SS: diagnosed at age 3 with
complications including avascular necrosis DISEASE of R hip acute chest
syndrome and pulmonary infarction DISEASE . Spleen autoinfarction.
-Pneumococcal vaccine [**2126**]
-Influenza vaccine [**2126**]
-H Flu & Meningococcal vaccine [**1-/2114**]
2) Hepatitis DISEASE C- Genotype 1B. Dx in [**2106**]'s believed to be due to
frequent transfusions. Liver biopsy [**3-24**] stage III fibrosis DISEASE . In
[**2120**] was on peg interferon & ribavarin but d/c'd due to
neutropenia DISEASE .
3) S/P cholecystectomy for gallstones DISEASE in [**2096**]'s
4) S/P appendectomy in [**2096**]'s
5. Proteinurea- Started lisinopril 2.5 mg 1 po daily [**4-/2127**]

Social History:
Married works as executive assistant for housing development.
Social smoking in high school none currently. Rare ETOH use
only on holidays. Denies drug use.

Family History:
Multiple family members on mother's side of family with sickle DISEASE
cell disease DISEASE .

Physical Exam:
Admission Physical Exam
Vital signs: 99.2 114/70 100 18 100%/2L
Gen: Appears uncomfortable complain in diffuse arthalgia.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. CTAB.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: Admission Date: [**2176-7-17**] Discharge Date: [**2176-7-22**]

Date of Birth: [**2093-9-13**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
none

History of Present Illness:
82 y/o F h/o DM2 DISEASE carotid stent on ASA/plavix HTN DISEASE a/w 4 days hx
of worsening SOB. There is some at rest but more noticable at
exertion. Developed orthopnea DISEASE PND but she did not notice
swelling DISEASE in her lower extremities. She noticed that today she
had chest tightness DISEASE but no chest pain DISEASE .
.
ROS: no n/v/d/fevers chills DISEASE or URI. No blood in stools there
have been no changes in her diet or her thyroid medications.


Past Medical History:
1. PVD DISEASE s/p [**Country **] stent
2. DM II
3. HTN DISEASE
4. hypothyroidism DISEASE
5. hyperlipidemia DISEASE
6. L eye detachment
7. h/o diabetes DISEASE inspidus after pregnancy - not an active issue
8. hearing loss DISEASE

Social History:
SH: Denies tobacoo history. Minimal alcohol use. Lives with
husband very supportive family.

Family History:
noncontributory

Physical Exam:
Admission Physical Exam:
PE: 185/54 77 38 99% NR
Gen: resp distress WDWN.
HEENT: peerla eomi ncat on non-rebreatherAdmission Date: [**2176-7-23**] Discharge Date: [**2176-7-26**]

Date of Birth: [**2093-9-13**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of Breath DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
82 y/o F h/o DM2 DISEASE carotid stent on ASA/plavix HTN DISEASE recently
admitted and discharged from [**Hospital Unit Name 196**] yesterday for CHF DISEASE exacerbation
and UTI DISEASE . PT became SOB Admission Date: [**2190-3-15**] Discharge Date: [**2190-3-23**]


Service: CCU

HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4924**] is an 85-year-old
male with a history of three vessel coronary artery disease DISEASE
status post coronary artery bypass graft in [**2181**] history of
congestive heart failure DISEASE with ejection fraction of 34% on
exercise MIBI in [**2189-6-12**] paroxysmal atrial fibrillation DISEASE
mitral regurgitation DISEASE who presents with two to three weeks of
increasing dyspnea DISEASE with minimal exertion. Denies dyspnea at
rest chest pain DISEASE paroxysmal nocturnal dyspnea DISEASE or orthopnea DISEASE .
His dyspnea DISEASE on exertion has been worsening over the last
couple of months but he has noticed over the last couple of
weeks that he is unable to walk even five yards without
significant symptoms. He was directly admitted for elective
Swan-Ganz tailored congestive heart failure DISEASE therapy.

PAST MEDICAL HISTORY:
1. Coronary artery disease DISEASE status post coronary artery
bypass graft in [**2181**]
2. Most recent cardiac catheterization [**2187-1-12**]Admission Date: [**2191-7-18**] Discharge Date: [**2191-7-24**] Service: CCU

THIS REPORT WILL BE CONCLUDED IN AN ADDENDUM.

HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
gentleman with a history of coronary artery disease DISEASE status
post three vessel coronary artery bypass graft in [**2181**] with
the following anatomy: Left internal mammary artery to left
anterior descendingAdmission Date: [**2192-3-25**] Discharge Date: [**2192-3-29**]

Date of Birth: Sex: M

Service: GEN [**Doctor First Name 147**]

The patient is transferred to the Cardiology Service on
[**2192-3-29**].

HISTORY OF PRESENT ILLNESS: This is an 87-year-old male with
an extensive medical history presented to the Emergency
Department on [**2192-3-25**] complaining of right lower quadrant
abdominal pain DISEASE since 2 a.m. Patient states that the pain DISEASE was
nonradiating. He also complained of dry heaves DISEASE without any
emesis DISEASE or diarrhea DISEASE . He did not report any fevers DISEASE or chills DISEASE .
He states that his fingersticks are within normal limits in
the 150s. He does not report any weight gain DISEASE or loss. He
states that he has had similar episodes of right lower
quadrant pain DISEASE which had been due to elevated lactate levels
and acidosis DISEASE and he had been treated conservatively in the
past.

CT scan of the abdomen which was done in the Emergency Room
on the date of admission showed dilated appendix concerning
for acute appendicitis DISEASE . Given the patient's extensive
medical history specifically his cardiac risk factors the
decision was made to conservatively treat the patient with
intravenous antibiotics.

PAST MEDICAL HISTORY:
1. Atrial fibrillation DISEASE with DDI pacer.
2. Noninsulin-dependent diabetes mellitus DISEASE .
3. Status post coronary artery bypass graft times three in
[**2181**].
4. Nephrolithiasis.
5. History of colon cancer DISEASE .
6. Status post episode of bowel ischemia DISEASE .
7. End-stage cardiomyopathy DISEASE with ejection fraction 20 to 30%
with mitral regurgitation DISEASE and tricuspid regurgitation DISEASE .
8. Chronic renal insufficiency DISEASE with a baseline creatinine of
1.6.

PAST SURGICAL HISTORY:
1. Status post coronary artery bypass graft times three in
[**2181**].
2. Sigmoid colectomy in [**2167**].

ALLERGIES: Penicillin.

MEDICATIONS:
1. Glyburide.
2. Coumadin.
3. Neurontin 100 mg p.o. t.i.d.
4. Aspirin 81 mg p.o. q. day.
5. Lisinopril 5 mg p.o. q.d.
6. Digoxin 0.125 mg p.o. q.d.
7. Allopurinol 200 mg p.o. q.d.
8. Bumex.
9. Carvedilol 12.5 mg p.o. b.i.d.
10. Zantac 150 mg p.o. b.i.d.

PHYSICAL EXAMINATION UPON EVALUATION: Temperature of 99.2
heart rate 72 respiratory rate 24 blood pressure 133/55
oxygen saturation 95% on room air. He is ill appearing but
in no acute distress. He is alert and oriented times three.
His sclerae are anicteric and his neck is supple without any
masses. His lungs have bibasilar crackles. His heart is a
regular rate and rhythm with a II/VI holosystolic murmur DISEASE .
His abdomen is nondistended and has normoactive bowel sounds.
The abdomen is soft and tender in the right lower quadrant
with guarding and rebound. His extremities are arm and have
1Admission Date: [**2192-3-25**] Discharge Date: [**2192-4-1**]


Service:


HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old
gentleman with coronary artery disease DISEASE status post coronary
artery bypass graft end-stage ischemic cardiomyopathy DISEASE
diabetes mellitus DISEASE and atrial fibrillation DISEASE status post VVI
recently admitted for ischemic colitis DISEASE treated with fluids.
The patient was last admitted in [**11-14**] with congestive heart failure DISEASE exacerbation and then discharged after treatment with
Lasix and Natrecor. On this admission the patient was
initially admitted to the surgical service on [**2192-3-25**] with
two days of right lower quadrant pain DISEASE that was concerning for
appendicitis DISEASE . The patient was treated conservatively with
levofloxacin and Flagyl and the abdominal pain DISEASE improved. The
patient was transferred to the [**Hospital Unit Name 196**] Service on [**2192-3-29**] for
electrophysiology procedure of changing his pacemaker to a
biventricular pacemaker.

PAST MEDICAL HISTORY: Atrial fibrillation DISEASE status post VVI
pacemaker.

Non-insulin-dependent diabetes mellitus DISEASE .

Three-vessel CABG in [**2181**].

Nephrolithiasis DISEASE .

History of colon cancer DISEASE .

Status post partial resection of the bowel.

History of an episode of bowel ischemia DISEASE .

End-stage cardiomyopathy DISEASE ejection fraction estimated at 30
percent.

Chronic renal insufficiency DISEASE .

ALLERGIES: PENICILLIN UNKNOWN REACTION.

MEDICATIONS: At home
1. Glyburide.
2. Coumadin.
3. Neurontin.
4. ASA 81 mg q.d.
5. Lisinopril unknown dose.
6. Digoxin unknown dose.
7. Allopurinol.
8. Bumex unknown dose.
9. Carvedilol unknown dose.


PHYSICAL EXAMINATION: Upon transfer to the [**Hospital Unit Name 196**] Service
temperature 98.1 degrees blood pressure 123/60 heart rate
70. An elderly gentleman in no apparent distress. Skin exam
notable for moles. No jugular venous distension in the neck.
Heart: Irregularly irregular rhythm S1 and S2. Lungs:
Clear to auscultation. Extremities: No edema DISEASE good pulses
throughout. Neurologic: Alert and oriented conversant
appropriate 5/5 strength.

LABORATORY DATA: Within normal limits.

CONCISE SUMMARY OF HOSPITAL COURSE: The patient is an 87-
year-old gentleman with coronary artery disease DISEASE status post
coronary artery bypass graft ischemic cardiomyopathy DISEASE
diabetes mellitus DISEASE and atrial fibrillation DISEASE status post VVI in
the past. The patient was initially admitted to the Surgical
Service for right lower quadrant pain DISEASE however treated
conservatively with resolution. The patient was now
transferred to the [**Hospital Unit Name 196**] Service on [**2192-3-29**] for pacemaker
change to a biventricular pacer.

PROBLEM LIST:
1. [**Name2 (NI) 4957**]y: The patient underwent biventricular pacer placement DISEASE on [**2192-3-30**] after his INR was less than
1.8. The patient tolerated the procedure well. The
patient was treated with prophylactic antibiotics for skin
flora with five doses of clindamycin given the patient's
penicillin allergy for a total five-day course. The
patient did well with a new biventricular pacemaker and
was discharged home with plans to follow up with Dr.
[**Last Name (STitle) **].

1. Coronary artery disease DISEASE : The patient is status post CABG
in the past. The patient was without symptoms in the
hospital and continued on his carvedilol dose. The
patient's aspirin was restarted after pacemaker placement.

1. Pump: Ejection fraction of 30 percent. The patient had
his pacemaker changed to a biventricular pacemaker. The
patient continued on lisinopril and digoxin. The patient
was clinically without signs of overload DISEASE throughout his
hospital stay.

1. Atrial fibrillation DISEASE : The patient's Coumadin was restarted
after his pacemaker change procedure.

1. Abdominal pain DISEASE : Resolved was likely ischemic colitis DISEASE
versus mild inflammation DISEASE that resolved with antibiotics.
The patient was continued on levofloxacin and Flagyl for
approximately a one-week course.

1. UTI DISEASE : The patient with methicillin-sensitive enterococcus DISEASE
on urine culture and treated with nitrofurantoin.

1. Chronic renal insufficiency DISEASE . The patient's creatinine was
at baseline and remained at baseline throughout his
hospital stay.

1. Diabetes mellitus DISEASE type 2: The patient was maintained on
his insulin sliding scale and fingersticks were within
normal limits. The patient's glyburide was restarted
prior to discharge.


CODE STATUS: The patient was full code as discussed and
confirmed with the patient.

DISCHARGE CONDITION: Stable.

DISCHARGE STATUS: Home with services.

DISCHARGE DIAGNOSES: Abdominal pain DISEASE .

Coronary artery disease DISEASE .

Congestive heart failure DISEASE .

Diabetes mellitus DISEASE .

Urinary tract infection DISEASE .

Biventricular pacemaker placement.

DISCHARGE MEDICATIONS:
1. Lisinopril 5 mg q.h.s.
2. Carvedilol 12.5 mg b.i.d.
3. Bumetanide 1 mg q.d.
4. Allopurinol 200 mg q.d.
5. Digoxin 0.125 mg q.d.
6. Gabapentin 100 mg t.i.d.
7. Ranitidine 150 mg q.d.
8. Aspirin 81 mg q.d.
9. Clindamycin 300 mg q.i.d. for 3 additional days.
10. Nitrofurantoin 100 mg q.i.d. for 5 days.
11. Glyburide 5 mg q.d.
12. Coumadin as instructed.


FOLLOW UP: Patient to follow up with Dr. [**Last Name (STitle) **] as well
as Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as well as his primary care physician.



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] [**MD Number(1) 4958**]

Dictated By:[**Last Name (NamePattern1) 4959**]
MEDQUIST36
D: [**2192-7-24**] 15:13:27
T: [**2192-7-25**] 08:13:26
Job#: [**Job Number 4960**]
Admission Date: [**2178-12-5**] Discharge Date: [**2178-12-21**]

Date of Birth: [**2114-2-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Doxepin / Levofloxacin / Oxycontin

Attending:[**First Name3 (LF) 287**]
Chief Complaint:
sepsis DISEASE

Major Surgical or Invasive Procedure:
none


History of Present Illness:
64 year-old gentleman with history of lung cancer DISEASE s/p right
pneumonectomy in [**2174**] severe COPD DISEASE recently discharged from
[**Hospital1 18**] MICU [**2178-12-2**] s/p tracheostomy and [**Month/Day/Year 282**] placement after
admission for respiratory failure DISEASE due to pneumonia DISEASE now
re-admitted to [**Hospital1 18**] with fever hypotension DISEASE .

On last admission patient unabled to be weaned from the
ventilator. After tracheostomy and [**Hospital1 282**] tube placement he was
discharged to [**Hospital1 **] on [**2178-12-2**] for vent weaning. While there
was constipated DISEASE according to wife. On [**2178-12-4**] patient became
agitated and hypotensive DISEASE to 82/58 and transferred back to [**Hospital1 18**]
ED.

On presentation to the [**Hospital1 18**] ED he was found to be hypotensive DISEASE
to 64/56 tachycardic to 120 febrile DISEASE to 102.8F and agitated.
Patient had several large loose bowel movements DISEASE in the ED. Also
found to have a drop in hct from 27.8 on arrival to ED to 22.9
on repeat draw one hour later. (Hct 26.9 on discharge.)
Of note femoral line attempted at [**Hospital1 **] but unsuccessful due
to patient's agitation DISEASE .

In the [**Last Name (LF) **] [**First Name3 (LF) **] attempt at IJ central line placement was
unsuccessful. A femoral central intravenous catheter was
placed. He was given IVF and started on Neosynephrine for blood
pressure support with good response. He received a total of 4
Liters of normal saline flagyl 500mg IV x1 vancomycin 1 gram
IV x1 ceftriaxone 1gram IV x1 2U PRBC.


Past Medical History:
1. Squamous cell lung carcinoma DISEASE status post right
pneumonectomy in [**2174**].
2. Prostate cancer DISEASE status post radical prostatectomy.
3. Perioperative pulmonary embolus DISEASE [**2174**].
4. Type 2 diabetes mellitus DISEASE .
5. Chronic obstructive pulmonary disease DISEASE .
6. Atrial fibrillation DISEASE .
7. Transient ischemic attack in [**2165**].
8. Gout DISEASE .
9. Atypical chest pain DISEASE since [**2164**].
10. Gastroesophageal reflux disease DISEASE .
11. Obstructive sleep apnea DISEASE . unable to tolerate BiPAP.
12. Hypertension DISEASE .
13. Colonic polyps DISEASE .
14. Hypercholesterolemia DISEASE .
15. Basal cell carcinoma DISEASE on his back.
16. Anxiety DISEASE .
17. Sciatica.
18. History of herpes zoster DISEASE .
19. multiple admissions for pneumonia DISEASE (including pseudomonas)
and bronchitis DISEASE last in [**10-31**] resulting in ventilator
dependence trach and [**Date Range 282**] placement
20. vitamin B12 deficiency.
21. Diastolic heart failure DISEASE . Echo [**7-31**]: LVEFAdmission Date: [**2196-4-15**] Discharge Date: [**2196-4-21**]


Service: MEDICINE

Allergies DISEASE :
Penicillins / Amiodarone Hcl

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
dark stools

Major Surgical or Invasive Procedure:
EGD on [**2196-4-16**]
Capsule Study [**2196-4-18**]


History of Present Illness:
Mr. [**Known lastname 4924**] is a [**Age over 90 **] year-old man with a history of coronary
arteryd disease diabetes hypertension DISEASE ischemic/radiation
proctitis DISEASE and colon cancer DISEASE who presents with a GIB DISEASE .
.
Two recent admission. The first ([**3-17**] - [**3-25**]) was for a lower GI
bleed DISEASE . A colonoscopy was notable for stigmata of a recent
internal hemorrhoid bleed DISEASE with post radiation proctitis DISEASE .
.
Then readmitted ([**4-5**] - [**4-11**]) this time with lower extremity
edema DISEASE thought to be secondary to a CHF DISEASE exacerbation. He was
diuresed 18 liters of fluid via Lasix gtt and Diuril with a dry
weight of 68.5kg achieved.
.
Since discharge from hospital has been relatively stable though
has been less active (previously could do 30 minutes on the
treadmill daily but now cannot do any). Over the last day he
reports approximately 10 hours of dark black stools. This has
not been associated with any abdominal pains nausea/vomiting DISEASE
chest pains shortness DISEASE of breath fevers/chills. He called PCP
and was advised to come to ED.
.
In the ED initial vitals showed T 97.9 HR 70 BP 122/42 100%
RA DISEASE . His hematocrit was noted to be 22 down from mid 33 just
four days prior. One liter of NS was given and unit of blood was
hung. Protonix IV was also given.
.


Past Medical History:
1. Coronary artery disease DISEASE
- CABG ([**5-/2181**]) with LIMA to LAD SVG to PDA SVG to OM3
- Cath ([**1-/2187**]) with 20% LM native 3VD and patent LIMA to LAD and
SVG to OM3. Occluded SVG to the PDA.
2. Congestive heart failure DISEASE
- Echo ([**3-19**]) with EF 40% (secondary to dyskinesis of the basal
inferior and posterior (inferolateral) walls and mild LVH DISEASE
3. Mitral regurgitation DISEASE (3Admission Date: [**2197-5-9**] Discharge Date: [**2197-5-13**]


Service: MEDICINE

Allergies DISEASE :
Penicillins / Amiodarone Hcl

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
bright red blood per rectum weakness DISEASE


Major Surgical or Invasive Procedure:
none

History of Present Illness:
History of Present Illness: [**Age over 90 **] year old male with medical
history pertinent for CAD Chronic Systolic CHF CKD DISEASE and DM who
presents with lower GI bleed. Patient began to feel ill and weak
yesterday evening and began to have diarrhea DISEASE . Diarrhea DISEASE was noted
to be mixed with bright red blood. He thinks that he had Admission Date: [**2198-9-20**] Discharge Date: [**2198-9-23**]


Service: MEDICINE

Allergies DISEASE :
Penicillins / Amiodarone Hcl

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
PEA arrest DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
History was obtained from his son and [**Name (NI) **] records:
Mr. [**Known lastname 4924**] is a [**Age over 90 **] year old male with a PMH significant for
severe MR ischemic cardiomyopathy DISEASE with severe left ventricular
dysfunction with an EF of 30% in [**2197-2-12**] NSVT DISEASE and a history
of ischemic bowel DISEASE due to overdiuresis. He was in his usual
state of health until a few days ago when he started feeling
very weak and fatigued.
.
His son went to pick him up tonight and as they were walking
toward the car he became fatigued and weak to the point where
he wanted to go back in the house. They turned around and as
they were walking toward the house he progressively became
weaker to the point where his son had to carry him and lay him
on a bench. They called EMS and between the time that they
called EMS and their arrival (Admission Date: [**2140-5-27**] Discharge Date: [**2140-6-2**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Back and leg pain DISEASE

Major Surgical or Invasive Procedure:
[**2140-5-27**] [**Doctor Last Name 1352**] L3-5 PSIF Lami


History of Present Illness:
[**5-27**] [**Doctor Last Name 1352**]

[**5-27**] L3-5 PSIF Lami 600 EBL

HPI: [**Age over 90 **] F L4-L5 spondylolisthesis DISEASE with mild stenosis at
L3-4 L4-5 and L5-S1 R leg pain DISEASE amb with walker
PMH: Angina HTN Cholesterol Skin Cancer DISEASE Insomnia OA
Restless leg syndrome DISEASE osteoperosis
MED: Fosamx 70 Atenlol 25 Aspirin 325 Nitro 0.6 mg SL
lipitor 10 Gabapentin 100 [**Hospital1 **] Tramadol 50 Triamterene-HCTZ
37.5-25 Calcium 500-vitD MVI DISEASE
ALL DISEASE : NKDA

Social History:
she lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has four
sons two of whom live close by.

Family History:
No premature CAD SCD DISEASE

Physical Exam:
RLE pain
BLE fires L2-S1 motor
Repsonds to senstion throughout BLE
Vitals: TEMP 97.1 HR 83 BP 124/68 RR 23 SAT 96% 3L NC
Gen: Pleasant well appearing elderly woman lying in bed in NAD

Eyes: No conjunctival pallor DISEASE . No icterus DISEASE .
ENT: MMM. OP clear.
CV: JVP low. Normal carotid upstroke without bruits DISEASE . PMI in 5th
intercostal space mid clavicular line. RR. nl S1 S2. No
murmurs rubs clicks or gallops. Full distal pulses
bilaterally. No femoral bruits DISEASE .
LUNGS: LAdmission Date: [**2140-8-11**] Discharge Date: [**2140-8-20**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Surgical Wound Draining

Major Surgical or Invasive Procedure:
Debridement of Laminectomy Wound

History of Present Illness:
Ms. [**Known lastname 4643**] is a [**Age over 90 **] year woman with a h/o CAD HTN CHF DISEASE with EF
of 25% s/p L4-L5 laminectomy with Dr. [**Last Name (STitle) 1352**] in [**5-/2140**]
presented from rehab facility with nonhealing lumbar surgical
wound. Wound began producing serous drainage a week prior to
presentation and started on Keflex [**8-6**]. Drainage was cultured
on [**8-6**] which grew heavy growth of MSSA and moderate alpha
strep DISEASE as a result was switched to Levaquin on [**8-8**] then
transferred to [**Hospital1 18**] [**8-11**].

Past Medical History:
s/p L4-5 laminectomy/fusion
CAD
HTN DISEASE
Hyperlipidemia DISEASE
Osteoporosis DISEASE
Osteoarthritis DISEASE
Skin Cancer DISEASE
Restless leg syndrome DISEASE

Social History:
She lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has four
sons two of whom live close by.


Family History:
No premature CAD SCD DISEASE

Physical Exam:
O: Tm:98.1 BP:115/64 HR:78 RR:18 SpO2:97% on RA DISEASE
General: Alert oriented to Person and Place no acute distress

HEENT: Sclera anicteric MMM oropharynx clear
Neck: supple no LAD
Lungs: Fine crackles on BL lung bases no wheezes ronchi
CV: Regular rate and rhythm
Abdomen: soft non-tender non-distended bowel sounds present
no rebound tenderness DISEASE or guarding no organomegaly DISEASE
GU: foley draining clear yellow urine
Ext: warm well perfused 2Admission Date: [**2167-4-28**] Discharge Date: [**2167-5-3**]

Date of Birth: [**2090-2-1**] Sex: F

Service: GEN [**Doctor First Name 147**]

ADMITTING DIAGNOSIS:
1. Pancreatic mass.

DISCHARGE DIAGNOSES:
1. Pancreatic mass.

PROCEDURES DURING ADMISSION:
1. Exploratory laparotomy lysis of adhesions DISEASE and
enucleation of a neuro-endocrine pancreatic mass.

HISTORY OF PRESENT ILLNESS: The patient is a 77 year old
female who presents with a history of a benign pancreatic
mass which causes her significant abdominal pain DISEASE . The
patient presents electively to have this resected.

PAST MEDICAL HISTORY:
1. Diabetes mellitus DISEASE .
2. Increased cholesterol.
3. Idiopathic hypertrophic subaortic stenosis DISEASE with an
echocardiogram [**3-/2167**] revealing an ejection fraction of
greater than 55%.

PAST SURGICAL HISTORY:
1. Pancreatic resection in [**2155**].

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS:
1. Aspirin.
2. Atenolol 125 mg p.o. twice a day.
3. Hydrochlorothiazide 25 mg p.o. q. day.
4. Zestril 40 mg p.o. q. day.
5. Prilosec 20 mg p.o. q. day.
6. Verapamil 240 mg p.o. twice a day.

PHYSICAL EXAMINATION: On examination the patient is awake
and alert in no apparent distress. Her heart is regular rate
and rhythm S1 S2. Her lungs are clear to auscultation
bilaterally. Abdomen soft. She has a well healed midline
scar.

HOSPITAL COURSE: The patient was admitted to the hospital
on [**2167-4-28**] and taken to the Operating Room for
enucleation of the pancreatic mass and lysis of adhesions DISEASE .

The patient tolerated the procedure well however in the
Post Anesthesia Care Unit she was noted to be extremely
somnolent. A blood gas revealed a pCO2 of 104. The patient
was followed closely. Given the fact that her blood gases
did not improve and it was thought that she had been
over-narcotized the patient was electively intubated and
transferred to the Intensive Care Unit for further
monitoring.

She remained hemodynamically stable the this event however
her pH was significantly decreased running from 7.04 to 7.1.
The patient's course in the Surgical Intensive Care Unit was
only notable for a transient rise in her liver function
tests. These however slowly trended down.

The patient was extubated and her respiratory status remained
good. She was started on her outpatient cardiac medications.
Her diet was fully advanced.

On [**2167-5-1**] the patient was transferred from the Intensive
Care Unit to the floor with intensive pulmonary toilet. Her
diet was advanced. A drain amylase was checked and revealed
a value of 3724. Value was rechecked. This value trended
down however given the fact that the patient was stable
her diet was advanced. She was tolerating p.o.

It was decided that she would be discharged home on her
preoperative medications on [**2167-5-3**] in stable condition.

She would also be discharged on:

DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q. day.

DISCHARGE INSTRUCTIONS:
1. She was told to follow-up with Dr. [**Last Name (STitle) 468**] in the office
and to call for a follow-up appointment.


[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 4984**]

Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36

D: [**2167-5-2**] 13:21
T: [**2167-5-2**] 16:01
JOB#: [**Job Number 4986**]
Admission Date: [**2168-10-4**] Discharge Date: [**2168-10-8**]

Date of Birth: [**2090-2-1**] Sex: F

Service: CCU

HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old female
with a history of type 2 diabetes hypertension DISEASE
hypercholesterolemia DISEASE and hypertrophic obstructive DISEASE
cardiomyopathy DISEASE who presents for ethanol septal ablation.
Her hypertrophic cardiomyopathy DISEASE was first discovered
approximately 2.5 years prior to admission during a
preoperative evaluation for her pancreatic surgery. Since
then she has noticed increasing dyspnea DISEASE on exertion and
lower extremity edema DISEASE .

PAST MEDICAL HISTORY:
1. Hypertrophic obstructive cardiomyopathy DISEASE with a resting
gradient of 90.
2. Type 2 diabetes DISEASE diet controlled.
3. Hypertension DISEASE .
4. Hypercholesterolemia DISEASE .
5. Coronary artery disease DISEASE .
6. Chronic renal insufficiency DISEASE with a baseline creatinine of
1.6.
7. Moderate-to-severe pulmonary hypertension DISEASE .
8. Status post pancreatic resection in [**2155**].
9. Status post pancreatic enucleation and resection for a
neuroendocrine tumor DISEASE .
10. GERD.

MEDICATIONS ON ADMISSION:
1. Lisinopril 20 mg p.o. q.d.
2. Atenolol 50 mg p.o. b.i.d.
3. Lasix 20 mg p.o. q.d.
4. Clonidine 0.1 mg p.o. b.i.d.
5. Aspirin 81 mg p.o. q.d.
6. Multivitamins.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: The patient is a Russian speaking female.
She is retired and formally worked as a secretary. She is
married and has one daughter. She denies any history of
alcohol use or smoking.

FAMILY HISTORY: Her mother had [**Name (NI) 2481**] disease. Her
father died from peritonitis DISEASE .

PHYSICAL EXAM ON ADMISSION: Temperature of 96.0 blood
pressure of 154/65 heart rate of 51 respiratory rate of 17
and oxygen saturation 98% on 4 liters nasal cannula.
Physical exam is notable for a 2/6 systolic ejection murmur
best heard at the left sternal border. The remainder of her
examination was normal.

LABORATORIES: Notable for a creatinine of 1.6.

HOSPITAL COURSE: The patient was admitted for ethanol septal
ablation for symptomatic hypertrophic obstructive DISEASE
cardiomyopathy DISEASE . The second septal perforator was ablated and
her gradient decreased from 90 to 5-10 mm Hg. The patient
tolerated the procedure well. For blood pressure control
the patient received metoprolol and captopril. Initially
the patient required nitroglycerin drip for blood pressure
control and eventually she was weaned off of it and started
on diltiazem extended release. At the time of discharge her
blood pressures were ranging from 120-140. The patient
remained on a temporary pacemaker following septal ablation
due to the risk of complete heart block DISEASE .

Following 48 hours this temporary pacemaker was removed
since the patient had remained in sinus rhythm. An
echocardiogram performed following the procedure showed an
improvement of her left ventricular outflow tract gradient as
well as improvement of the severity of her mitral
regurgitation. Left ventricular function with the exception
of the basal septum remained vigorous throughout.

The patient had a brief episode of delirium DISEASE following the
procedure which was resolving by the time of discharge. Her
creatinine also slightly elevated from 1.6 to 1.9 that
remained stable and was felt to be within her normal range.
Her diabetes DISEASE was well controlled with regular insulin-sliding
scale.

She did have some mild pulmonary edema DISEASE and was given Lasix
prn.

CONDITION ON DISCHARGE: Stable.

DISCHARGE STATUS: Patient is discharged to home. She
requires no home services.

DISCHARGE DIAGNOSES:
1. Hypertrophic obstructive cardiomyopathy DISEASE status post
ethanol septal ablation.
2. Diastolic heart failure DISEASE .
3. Chronic renal insufficiency DISEASE .
4. Hypertension DISEASE .
5. Coronary artery disease DISEASE .
7. Hypercholesterolemia DISEASE .
8. Gastroesophageal reflux disease DISEASE .
9. Pulmonary hypertension DISEASE .

DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Atorvastatin 10 mg p.o. q.d.
3. Diltiazem sustained release 120 mg p.o. q.d.
4. Toprol XL 150 mg p.o. q.d.
5. Lisinopril 40 mg p.o. q.d.
6. Pantoprazole 40 mg p.o. q.d.
7. Furosemide 20 mg p.o. q.d.
8. Multivitamin one p.o. q.d.

FOLLOW-UP PLANS: The patient is scheduled to followup with
her cardiologist Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**]. She is also due to be
scheduled for an outpatient MRI of her kidneys looking for
renal artery stenosis DISEASE .



[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**] M.D. [**MD Number(1) 4992**]

Dictated By:[**Name8 (MD) 4993**]

MEDQUIST36

D: [**2168-10-10**] 14:14
T: [**2168-10-11**] 08:24
JOB#: [**Job Number 4994**]
Admission Date: [**2169-6-22**] Discharge Date: [**2169-6-29**]

Date of Birth: [**2090-2-1**] Sex: F

Service: [**Doctor First Name 147**]

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 4995**]
Chief Complaint:
right colon mass

Major Surgical or Invasive Procedure:
right colectomy

History of Present Illness:
Patient is a 79 year old Russian speaking female with history of
cardiopulmonary disease DISEASE diagnosed with adenocarcinoma of the right colon DISEASE in [**2169-5-18**].

Past Medical History:
1. hypertension DISEASE
2. diabetes type II DISEASE
3. hypercholesterolemia DISEASE
4. coronary artery disease DISEASE
5. chronic renal failure DISEASE
6.pulmonary hypertension-
7.left ventricle outflow tract obstructiondiastolic heart
failure-ejection fraction of 70%
8. gastro-esophageal reflux disease DISEASE

pancreatic resection [**2155**] [**2166**]- required intubation with
history of delirium DISEASE
resection of neuroendocrine tumor DISEASE
septal ablation [**2164**]

Social History:
positive for tobacco negative for alcohol and recreation drug
use.

Family History:
non-pertinant

Physical Exam:
On discharge patient is afebrile with stable vitals. Abodomen
is soft and non tender on exam. Abdominal incision has no
evidence of infection DISEASE and staples are in place.

Pertinent Results:
[**2169-6-22**] 06:59PM TYPE-MIX PO2-42* PCO2-50* PH-7.27* TOTAL
CO2-24 BASE XS--4
[**2169-6-22**] 06:59PM O2 SAT-70
[**2169-6-22**] 06:58PM TYPE-ART TEMP-37.5 RATES-[**10-23**] TIDAL VOL-500
PEEP-8 O2-40 PO2-117* PCO2-43 PH-7.33* TOTAL CO2-24 BASE XS--3
INTUBATED-INTUBATED
[**2169-6-22**] 06:45PM WBC-9.7 RBC-3.73* HGB-11.8* HCT-35.0* MCV-94
MCH-31.5 MCHC-33.6 RDW-13.4
[**2169-6-22**] 02:55PM TYPE-ART PO2-82* PCO2-43 PH-7.29* TOTAL
CO2-22 BASE XS--5
[**2169-6-22**] 02:55PM HGB-11.3* calcHCT-34
[**2169-6-22**] 01:49PM HCT-29.6*
[**2169-6-22**] 12:43PM TYPE-ART PO2-96 PCO2-45 PH-7.25* TOTAL CO2-21
BASE XS--7
[**2169-6-22**] 11:47AM TYPE-ART PO2-97 PCO2-53* PH-7.22* TOTAL
CO2-23 BASE XS--6 INTUBATED-INTUBATED
[**2169-6-22**] 11:22AM WBC-13.9*# RBC-3.92* HGB-12.4 HCT-36.1 MCV-92
MCH-31.6 MCHC-34.4 RDW-13.2

Brief Hospital Course:
Patient was taken to the operating room on [**2169-6-22**] for
the above stated procedure. The patient was hemodynamically
stable throughout the operation requiring a small amout of
pressors. She was then admitted to the intensive care unit
post-operatively intubated and monitored with a swan cathater
that was placed intraoperatively. Rising pulmonary artery
pressures were noted- 60/30's. Patient [**Last Name (un) 4996**] a course of
kefzol/flagyl which was continued for 2 days. On post
operative day 1 the patient was extubated and remained nothing
by mouth. On post operative day 2 patient experienced shortness DISEASE
of breath satting 89% on 2 liters. Intra-venous fluids were
decreased from 100 cc per hour to 80 than 50cc and remained on
[**1-19**] liters oxygen. Patient was noted to have good urinary output
of 90- 100cc DISEASE per hour. On post operative day 2 intra-venous
fluids were dereased to 30 cc per hour oxygen saturation
remained good on 3 liters and urinary output was also adequate
and she was transferred to the floor and advanced to clears. On
post-operative day 4 patient tolerated clears. On
post-operative day 5 patient was noted to be slightly distended
and was made nothing by mouth. On post-operative day 6 patient
reported to pass flatus clears were advance and she was
evalutated by physical therapy. Home physical therapy was
reccommended. Also on post-operative day 5 family noted some
acute mental status changes she was seen by neurology. On
post-operative day 6 mental status was noted to have greatly
improved per family futher neuro workup was deferred to
outpatient. Patient was discharged on post-operative day 7 with
home services.

Medications on Admission:
lasix
cardura
toprol
aricept
lisinopril
lipitor


Discharge Medications:
not requiring narcotics

Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services

Discharge Diagnosis:
adenocarcinoma of the right colon DISEASE


Discharge Condition:
good

Discharge Instructions:
Do not soak incisions in [**Last Name (LF) 4997**] [**First Name3 (LF) **] shower and then pat incision
line dry DISEASE . Resume DISEASE prehospital medications.
[**Month (only) 116**] take tylenol for pain DISEASE .

Followup Instructions:
Patient is to call and make appointment to be by Dr. [**Last Name (STitle) 1888**] in
[**11-18**] weeks.
Please follow up with neurologist.



Admission Date: [**2171-12-2**] Discharge Date: [**2171-12-21**]

Date of Birth: [**2090-2-1**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Nitroglycerin

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of breath DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is an 81 year old Russian-speaking female with a
history of HOCM DISEASE s/p septal EtOH ablation in [**2167**] CHF DISEASE EF Admission Date: [**2104-10-7**] Discharge Date: [**2104-10-20**]

Date of Birth: [**2046-8-21**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Transferred from OSH for management of CAD PCI vs CABG

Major Surgical or Invasive Procedure:
[**10-15**] CABG x 4


History of Present Illness:
This is a 58 year old male with a history of hypertension DISEASE type
II DM hyperlipidemia chronic renal insufficiency DISEASE and
polysubstance abuse DISEASE who presents from an OSH s/p cardiac cath
for further management of his coronary disease DISEASE . Per report from
[**Hospital6 5016**] Mr. [**Known lastname **] was admitted on [**2104-9-30**] with
epigastric discomfort that subsequently developed into chest
pain DISEASE radiating to the jaw and left shoulder. Per the patient he
has been having intermittent abdominal pain DISEASE associated with
nausea DISEASE and vomitting for approximately 2.5 weeks to 1 month. The
abdominal pain DISEASE is in the epigastrium not associated with eating
or with position and is non-radiating DISEASE . The abdominal pain DISEASE has
resolved since being in the hospital.
.
On the evening of [**2104-9-30**] he reports that his abdominal pain DISEASE
was accompanied by 8 out of 10 substernal chest pain DISEASE . The chest
pain DISEASE radiated to his jaw and left shoulder. This pain DISEASE lasted for
approximately 1 hour and resolved in the ED at [**Hospital3 **]. He
does not recall precipitating factors for this chest pain DISEASE . But
does report that his roommate informed him that he had Admission Date: [**2179-2-1**] Discharge Date: [**2179-2-8**]

Date of Birth: [**2114-2-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Doxepin / Levofloxacin / Oxycontin

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
chest pain DISEASE

Major Surgical or Invasive Procedure:
stenting of SVC


History of Present Illness:
64 yo man with h/o lung CA s/p R pneumonectomy severe COPD DISEASE
with prolonged respiratory failure DISEASE requiring prolonged trach (2
months ago) wean presents from rehab with increased bilateral
upper extremety edema DISEASE (present since [**10-31**] admission) and left
sided chest pain DISEASE for 2 days(continuous for about 20hrs). Patient
denies any fevers chills cough DISEASE radiation diaphoeris no
similar pain DISEASE in past no pleuritic nature n/v/diaphoresis. No
associated triggers or change with positions no pain DISEASE currently.
He had been doing well at rehab this past week after ativan and
valium were stopped and started on haldol with good relief.

Past Medical History:
1. Squamous cell lung carcinoma DISEASE status post right
pneumonectomy in [**2174**].
2. Prostate cancer DISEASE status post radical prostatectomy.
3. Perioperative pulmonary embolus DISEASE [**2174**].
4. Type 2 diabetes mellitus DISEASE .
5. Chronic obstructive pulmonary disease DISEASE .
6. Atrial fibrillation DISEASE .
7. Transient ischemic attack in [**2165**].
8. Gout DISEASE .
9. Atypical chest pain DISEASE since [**2164**].
10. Gastroesophageal reflux disease DISEASE .
11. Obstructive sleep apnea DISEASE . unable to tolerate BiPAP.
12. Hypertension DISEASE .
13. Colonic polyps DISEASE .
14. Hypercholesterolemia DISEASE .
15. Basal cell carcinoma DISEASE on his back.
16. Anxiety DISEASE .
17. Sciatica.
18. History of herpes zoster DISEASE .
19. multiple admissions for pneumonia DISEASE (including pseudomonas)
and bronchitis DISEASE last in [**10-31**] resulting in ventilator
dependence trach and [**Date Range 282**] placement
20. vitamin B12 deficiency.
21. Diastolic heart failure DISEASE . Echo [**7-31**]: LVEFAdmission Date: [**2152-11-25**] Discharge Date: [**2152-12-2**]

Date of Birth: [**2088-1-16**] Sex: F

Service: NEUROLOGY

Allergies DISEASE :
Percocet

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Headache DISEASE & vomiting DISEASE

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Pt is a 64 year old woman with hx of breast CA TIA DISEASE 's and
CAD s/p CABG and R cavernous carotid aneurysm DISEASE s/p clipping
transferred from [**Hospital3 **] after having been found to have
intracerebral hemorrhage DISEASE .
Last night around 7 pm she was alone at home (lives in a
retirement community) and developed headache dizziness nausea DISEASE
and vomiting DISEASE . She also had some diarrhea DISEASE and thought that she
had
a viral illness DISEASE . Went to bed difficulty sleeping because of her
vomiting DISEASE . This morning she still felt dizzy and weak. Her son
came to visit her later in the morning and noted a prominent R
facial droop DISEASE and slurred DISEASE speech. He took her to [**Hospital6 5019**] where a CT was performed that was concerning for
subarachnoid blood. She was sent to [**Hospital1 18**] for further
evaluation.
In ED repeat CT performed that showed hypodensity DISEASE in R anterior
frontal lobe c/w subacute or acute infarct DISEASE with 2x2 cm
intraparenchymal hemorrage DISEASE in posterior portion of the infarct DISEASE
wtih minimal subarachnoid extension. She is admitted for further
management and evaluation.

ROS:
Negative for recent falls head or neck trauma DISEASE change in mental
status fevers DISEASE recent travel rash DISEASE sick contacts. Pt says that
today she feels tired and has some unsteadiness DISEASE when she walks.
Also thinks that her L arm is a bit weaker than the right.


Past Medical History:
vertigo DISEASE
breast CA DISEASE s/p chemo and radiation (per son at least 10 years
ago)
brain aneursym (R cavernous carotid) s/p DISEASE clipping Admission Date: [**2135-4-20**] Discharge Date: [**2135-5-9**]

Date of Birth: [**2055-11-4**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
R toe pain DISEASE

Major Surgical or Invasive Procedure:
Intubation and extubation x3


History of Present Illness:
79M with history of DMII CAD s/p MI PVD COPD DISEASE hyperchol HTN DISEASE
who was admitted to the Vascular Surgery service from his
cardiologist's office with Admission Date: [**2135-8-15**] Discharge Date: [**2135-8-30**]

Date of Birth: [**2055-11-4**] Sex: M

Service: VSU


CHIEF COMPLAINT:
1. Peripheral vascular disease DISEASE with claudication DISEASE right
greater than left and right foot rest pain DISEASE .
2. Asymptomatic carotid disease DISEASE with internal carotid artery
80 to 90% left common carotid 68 to 69% right internal
carotid artery 70 to 79% with a left subclavian steel.

Patient was recently hospitalized in [**Month (only) 116**] for respiratory
failure DISEASE and was discharged in [**2135-4-25**] and spent 2 months in
rehab. He was discharged from rehab on [**2135-6-20**] to home.
He returns now for carotid endarterectomy and
revascularization of the right extremity.

REVIEW OF SYSTEMS: Is positive for claudication right
greater than left x4 years now with right foot pain DISEASE which
has increased since discharge. He denies any syncope DISEASE
seizure amaurosis DISEASE or hemiparesis seizures DISEASE . Denies DISEASE any chest
pain DISEASE paroxysmal nocturnal dyspnea orthopnea edema DISEASE
palpitations DISEASE . He denies prostatism melena DISEASE or bloody stools.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS ON ADMISSION: Included Norvasc 10 mg daily
Toprol XL 100 mg daily Nexium 20 mg daily Captopril 25 mg
t.i.d. Glipizide 10 mg q A.M. and Lipitor 10 mg q.d.

ILLNESSES: Included enuresis DISEASE status post cystoscopy with
cystometrics in [**2131-3-26**]. History of coronary artery
disease with myocardial infarction DISEASE x3 with a failed right
coronary angioplasty stenting complicated by right coronary
dissection requiring intra-aortic balloon support in [**2121**].
Peripheral vascular disease DISEASE . Left hip and pelvic fracture DISEASE
secondary to fall in [**2132-2-23**]. Left upper lobe cancer DISEASE
status post right upper lobectomy with chest wall resection
mediastinal node dissection. Bronchoscopy and mediastinoscopy
and scalene node biopsy in [**2132-2-23**]. History of
hypertension DISEASE . History of type 2 diabetes mellitus DISEASE on oral
agents. History of chronic obstructive pulmonary disease DISEASE .
History of VRE DISEASE . History of ventral hernia DISEASE . History of non-
Hodgkin's lymphoma DISEASE by scalene node biopsy. History of
ventilator-induced DISEASE pseudomonas pneumonia DISEASE . History of
congestive heart failure DISEASE compensated.

SOCIAL HISTORY: The patient is married x57 years. Lives with
his spouse. [**Name (NI) **] is retired. He ambulates. He is limited
secondary to his foot pain DISEASE . Patient's cardiologist is Dr.
[**Last Name (STitle) **]. The patient admits to tobacco use 200 pack-years of
smoking. He has not smoked since his lung resection in [**2132-2-23**].

PHYSICAL EXAMINATION: He is alert oriented in no acute
distress. HEENT examination: No jugular venous distension DISEASE .
Carotids are palpable bilaterally 1Admission Date: [**2194-2-21**] Discharge Date: [**2194-3-1**]

Date of Birth: [**2146-9-1**] Sex: M

Service: Transplant [**Doctor First Name **]


HISTORY OF PRESENT ILLNESS: Patient is a 47 year-old male
with polycystic kidney disease DISEASE and impending renal failure DISEASE .

PHYSICAL EXAMINATION: He is a well-developed male in no
acute distress. He is 268 pounds with a blood pressure of
133/86. Heart rate is 106. Neck is supple without masses.
Heart is regular rate and rhythm with S1 and S2 clearly
heard. No murmur rub or gallop were appreciated. His lungs
were clear to auscultation bilaterally. His abdomen was
soft distended and the kidneys and liver are easily palpable
bilaterally. Bowel sounds are normal and present.
Extremities are with 1 to 2Admission Date: [**2102-5-23**] Discharge Date: [**2102-5-26**]

Date of Birth: [**2043-7-3**] Sex: M

Service: MED


HISTORY OF PRESENT ILLNESS: Mr. [**Name13 (STitle) 9564**] is a 58-year-old male
with hypertension coronary artery disease DISEASE and AAA who was
sent to the emergency department for evaluation of
hypotension DISEASE . The patient was seen in the primary care
physician's office on the date of admission and was found to
have a systolic blood pressure in the 70s. The patient had
been complaining of the neck pain DISEASE over the past several weeks
with radiation down his mid back. He also notes a decrease
in appetite times several weeks and approximately 15-pound
weight lost over the last two months. The patient denies any
abdominal pain nausea vomiting DISEASE or diarrhea DISEASE . The patient's
last bowel movement DISEASE was on the day prior to admission and
there was no blood in the stool. The patient does states
that he has been fatigued recently and has felt chilled.
Although denies any cough shortness DISEASE of breath chest pain DISEASE
or mental status changes. In the emergency department the
patient was given 4 liters of normal saline and was found to
have hyperkalemia DISEASE as well as acute renal failure DISEASE . The
patient was treated with bicarbonates calcium gluconate
D50 and insulin for his hyperkalemia DISEASE . ABG on admission
showed a pH of 7.14 a PCO2 of 22 PO2 of 138 and a
bicarbonate of 8. The patient developed chest pain DISEASE following
an abdominal CT scan in the emergency department but EKG
showed no changes. Chest pain DISEASE resolved spontaneously without
intervention. The patient was given vancomycin
levofloxacin and Flagyl in the emergency department due to
concern for sepsis DISEASE .

PAST MEDICAL HISTORY: Coronary artery disease DISEASE status post MI
in [**2099**] and right coronary artery stent for a 95 percent
lesion.

Hypotension DISEASE .

Bladder cancer DISEASE status post prostocystectomy in [**2091**] followed
by ileoneobladder.

Status post right inguinal hernia DISEASE surgery in [**2102-3-23**].

Left uretero-ileal anastomosis stricture DISEASE .

AAA with most recent scan showing an aneurysm DISEASE 4 cm in
diameter.

History of skin cancer DISEASE .

MEDICATIONS ON ADMISSION:
1. Lisinopril 10 mg p.o. q. day
2. Lopressor 25 mg p.o. b.i.d.
3. Aspirin 81 mg p.o. q. day.


SOCIAL HISTORY: The patient works as a bartender. He lives
with his wife. [**Name (NI) **] smokes two to three cigarettes per day and
has greater than a 100-pack-year smoking history in total.
He also has one alcoholic drink per day.

FAMILY HISTORY: Positive for coronary artery disease DISEASE
diabetes DISEASE and brain cancer DISEASE .

PHYSICAL EXAMINATION: On admission vital signs temperature
of 97.1 heart rate ranging from 96-110 blood pressure
ranging from 68-106/38-44 respiratory rate of 16-20 and
oxygen saturation is 100 percent on 2 liters by nasal
cannula. In general the patient is well appearing and in no
apparent distress. HEENT: Reveals pupils equally reactive
and round to light with no sclera icterus DISEASE and dry DISEASE mucous
membranes. Neck shows flat JVD. Lungs are clear to
auscultation anteriorly and laterally. Cardiovascular exam
regular rate and rhythm with no murmurs. Abdominal exam:
Soft nontender and nondistended with positive bowel sounds
and stool with OB negative. There is a well healing incision
in the right groin. Extremities no lower extremity edema DISEASE
and no rashes. Neurologic exam: Alert and oriented times 3.
Cranial nerves are intact. Strength is [**4-26**] in the upper and
lower extremities. There is limited range on the neck
extension and full range on neck flexion. There is no point
tenderness DISEASE over the spine.

LABORATORY DATA: On admission showed him a hematocrit of
26.9 down from his baseline of 40 his potassium is elevated
at 6.6 his creatinine is elevated at 2.3 from his baseline
0.9 lactate is 0.5 CK is 21 troponin is 0.05. Chest x-ray
shows no CHF DISEASE or infiltrate. Abdominal CT scan shows stable
abdominal aortic aneurysm DISEASE with no evidence of leak. It
measures 3.3 to 4.3 cm in diameter. There is a non
obstructing left renal calculus DISEASE and there is ileal loop
diversion of the right aorta. ABG ph of 7.14 PCO2 of 22
PO2 of 138 bicarbonate of 8. Renal ultrasound showed mild
hydronephrosis DISEASE of the right kidney and moderate
hydronephrosis DISEASE of the left kidney with a distended bladder.
The Foley was flushed and there was no evidence of
hydronephrosis DISEASE following flush of the Foley and urination of
two liters of fluid. UA shows no bacteria and 0-2 white
blood cells with negative nitrates and negative leucocyte
Estrace. Urine electrolytes showed a postive urine anion gap
of 10. EKG is sinus rhythm with a rate of 65. His PR
interval is slightly prolonged at 206 millisecond. There are
ST elevations in V2 through V5 which purpose on previous EKG
of [**2102-2-20**].

HOSPITAL COURSE: Hypotension. The patient was admitted to
the MICU for evaluation of hypotension DISEASE . He was started on
aggressive fluid resuscitation and dopamine drip for blood
pressure management. Dopamine was eventually weaned off on
the day following admission. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test to evaluate
for renal insufficiency DISEASE was within normal limits. Due to
concern for sepsis DISEASE the patient was started on antibiotics
although there was no evidence for an infection DISEASE . White blood
count was not elevated. The patient remained afebrile
throughout the remainder of the hospitalization. Nitrate was
within normal limits. Chest x-ray was clear. UA was
negative. All blood and urine cultures were no growth today.
Because of the very low suspicion for sepsis DISEASE all antibiotics
were stopped on hospital day 3. With aggressive IV fluids
because the patient's blood pressure eventually improved back
to baseline. At the time of discharge the patient's
outpatient blood pressure medications including lisinopril
and metoprolol had not been started. The patient was advised
to not take these medications until he was seen by his
primary care physician as an outpatient in one to two weeks.

Anemia DISEASE . The patient was admitted with hematocrit of 26.9
from his baseline of 40. He was transfused four units on
admission and his hematocrits stabilized at 33. Stools were
guaiac negative and iron studies showed normal iron and low
TIBC. Abdominal CT scan showed no leak or rupture DISEASE of the
abdominal aortic aneurysm DISEASE and there was no retroperitoneal
bleed. Hemolysis DISEASE abs were negative. There was no evidence
for DIC DISEASE . Folate was within normal limits. B12 was found to
be low and he was started on B12 supplements.
Supplementation was initially through IM but it was
eventually switched to p.o. as an outpatient. It is believed
that his vitamin B12 deficiency is due to the removal of his
terminal ileum to make the neobladder. Now its concern that
the patient may not be able to adequately absorb the p.o.
vitamin B12 but his primary care physician will decide as an
outpatient if he should be started vitamin B12 IM injections
instead. The patient's hematocrit was stable at 33 at the
time of discharge.

Nonanion gap metabolic acidosis DISEASE . The patient's ABG on
admission was 7.14 22 138 and 8. Urine anion gap was
positive. Acidosis improved with bicarbonate drip and volume
resuscitation. Following discussion with urology it was
determined that neobladder obstruction was an important cause
for his non anion gap metabolic acidosis DISEASE . The mucosa of the
ilium has a tendency to excrete bicarbonate. Since the
patient neobladder had been obstructed for some time prior to
presentation the patient was likely excreting large amounts
of bicarbonate into his urine. With the bicarbonate drip and
fluid resuscitation his bicarbonate improved closer to
baseline. At the time of discharge the patient's
bicarbonate was 18. The patient's acidosis DISEASE resolved slowly
throughout the course of hospitalization.

Acute renal failure DISEASE . The patient was found to be in acute
renal failure DISEASE on hospital admission with creatinine of 2.3
from his baseline of 0.9. Renal ultrasound showed bilateral
hydronephrosis DISEASE which immediately resolved following flushing
of the Foley and removal of the mucous blood obstructing the
neobladder outlets. The patient was also hydrated for
hypotension DISEASE which may have led to some acute tubular
necrosis DISEASE in addition to obstructive renal failure DISEASE . At the
time of discharge the patient's creatinine was 1.2. The
patient was encouraged to drink plenty of fluids to maintain
good oral hydration.

Spinal stenosis. The patient had complaint of neck pain DISEASE for
several weeks prior to presentation. Due to concern for
possible osteomyelitis DISEASE or discitis DISEASE as the source of infection DISEASE
leading to hypotension DISEASE a MRI without contrast was obtained.
There was no evidence for osteomyelitis DISEASE or discitis DISEASE .
However he was found to have a severe cervical spine
stenosis at several levels with cord impression. The C3-4
level showed moderate sized antral disc protrusion with
spinal stenosis DISEASE and compression of the spinal cord DISEASE in C3
nerve roots. C4 side has mild disc bulge with mild
compression of spinal cord DISEASE and C4 nerve roots. C5-6 showed
mild disc bulge with mild compression of the spinal cord DISEASE and
C5 nerve roots. C6-7 showed mild disc bulge with no evidence
of compression DISEASE . Neurosurgery was consulted regarding these
findings. They felt that the spinal cord compression DISEASE was not
a neurosurgical emergency. They did not feel that steroids
were indicated in this situation. Neurosurgery recommended a
followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an outpatient. Neurological
exam was nonfocal and the patient did not have any numbness DISEASE
weakness tingling DISEASE or incontinence DISEASE . The patient was given a
soft cervical neck collar to wear at all times except when
he is sleeping.

CONDITION ON DISCHARGE: Hemodynamically stable ambulating
without assistance and breathing in room air.

DISCHARGE STATUS: The patient is discharged to home with a
soft cervical neck collar.

DISCHARGE DIAGNOSES: Hypotension due to hypovolemia DISEASE .

Anemia DISEASE due to B12 deficiency DISEASE .

Non anion gap metabolic acidosis DISEASE .

Acute renal failure DISEASE due to obstruction DISEASE and possible acute
tubular necrosis DISEASE .

Severe cervical spine stenosis DISEASE with cord compression DISEASE .

Abdominal aortic aneurysm DISEASE .

Hyperkalemia DISEASE .

DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Vitamin B12 [**2097**] mcg p.o. q.d.
3. Multivitamins p.o. q.d.

The patient was asked to not take his metoprolol or
lisinopril until he saw his primary care physician.

FOLLOW UP: The patient was given the phone number to call
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of neurosurgery to discuss his spinal stenosis
and cord impingement DISEASE .

The patient is scheduled to follow up with Dr. [**First Name8 (NamePattern2) 487**]
[**Last Name (NamePattern1) **] in cardiology on [**2102-8-15**].

The patient is asked to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] in
one to two weeks.



[**Name6 (MD) **] [**Last Name (NamePattern4) **] [**MD Number(1) 9565**]

Dictated By:[**Doctor Last Name 9566**] MEDQUIST36
D: [**2102-5-26**] 15:53:26 T: [**2102-5-28**] 06:06:26
Job#: [**Job Number 9567**]
Admission Date: [**2105-2-12**] Discharge Date: [**2105-3-2**]

Date of Birth: [**2043-7-3**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
productive cough fever DISEASE

Major Surgical or Invasive Procedure:
intubation
bronchoscopy

History of Present Illness:
Mr. [**Known lastname 7931**] is a 61-year-old male w/ recently diagnosed multiple
myeloma DISEASE during an admission to an OSH for pneumonia DISEASE who
currently presents with productive cough DISEASE (yellow/brown and
bloody) subjective fever DISEASE chillls x 3 days. Admits to increased
fatigue DISEASE and increased shortness of breath DISEASE (which has never been
this bad before) but denies myalgias nausea vomiting DISEASE
abdominal pain diarrhea chest pain palpitations DISEASE . Says he
feels exactly like he felt in [**Month (only) 404**] when he had PNA. Recently
discharged from [**Hospital1 18**] [**2105-2-7**] for treatment of hypercalcemia DISEASE [**1-23**]
to multiple myeloma DISEASE . Had been feeling well when discharged but
returned to work Monday [**2-9**] which is when he began to fell ill.

.
In ED had CXR suspicious for LUL and RLL PNA. Given 1 dose of
Levaquin 500 mg IV 1 dose of Vancomycin 1 g IV 80 mEq KCL and
motrin 400 mg po. Admitted to medicine for treatment of PNA.

Past Medical History:
-Multiple Myeloma with hypercalcemia DISEASE diagnosed [**12-28**]
-Muscle invasive bladder CA status post radical prostatectomy
and cystectomy in [**2091**] with creation of neobladder
-Hypertension
-AAA with slight interval increased size last measured [**7-27**]
-h/o MI and CAD s/p RCA stenting in [**2099**]
-EF of 60-65% [**12-28**]
-DVT in his upper extremity in [**2101**]
-COPD
-Tobacco use 51 pack/year history
-Pneumonia in [**7-/2104**] [**12/2104**] (LUL)
-Recently diagnosed AFib DISEASE on [**2105-1-7**] for which he is on Coumadin.

-Basal cell carcinoma on his right cheek [**2098**]
-Spinal stenosis
-B12 deficiency

Social History:
He lives in [**Hospital1 **] and works as a bartender. He has been
married for 21 years. He has a daughter who is 19 years old and
lives with him. He has two other daughters that are estranged
from him. He smoked a pack per day since [**2053**] but claims to only
smoke [**3-26**] cigarettes a day currently. He drinks two to three rum
drinks a day he uses marijuana daily.

Family History:
Significant for a mother who is deceased with breast cancer DISEASE and
[**Month/Day (1) 1902**] after MI at age 60. His father died at age 71 and had
Alzheimer's disease DISEASE . He has one brother with diabetes DISEASE
hypertension DISEASE and coronary artery disease DISEASE .


Physical Exam:
VS: T 96.7 (100.0 in ED) P 72 BP 140/64 RR 20 Pox 98% RA DISEASE
GEN: slightly uncomfortable with SOB irritable DISEASE bloody mucus in
tissue in trash can at bedside.
HEENT: PERRL anicteric sclerae. Oropharynx moist without
erythema lesion DISEASE or thrush.
NECK: Supple.
CV: RRR no MGRC.
LUNGS: poor air movement diffusely LUL Admission Date: [**2125-6-19**] Discharge Date: [**2125-6-25**]

Date of Birth: [**2091-7-1**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Betadine

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
DOE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
HPI:
33M with pmh of borderline htn presenting with complaint DISEASE of new
PND and DOE. Pt was in his USOH until 2 weeks prior when he
began to have difficulty sleeping due to waking up after
sleeping for Admission Date: [**2181-5-20**] Discharge Date: [**2181-6-19**]

Date of Birth: [**2133-9-15**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Zosyn / Seroquel

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
cardiac arrest DISEASE

Major Surgical or Invasive Procedure:
[**2181-5-26**] Endotracheal intubation
[**2181-5-27**] PICC placement
[**2181-5-31**] central line placement
[**2181-6-11**] cardiac catheterization
[**2181-6-15**] Coronary artery bypass graft surgery x 5 (left
internal mammary artery Admission Date: [**2119-8-15**] Discharge Date: [**2119-9-1**]

Date of Birth: [**2065-1-10**] Sex: F

Service: MEDICINE

Allergies DISEASE :
Codeine

Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
VFib arrest

Major Surgical or Invasive Procedure:
cardiac catheterization and stenting
blood transfusions
AICD placement
intubation
central line placement


History of Present Illness:
Ms [**Known lastname 9581**] is a 54 y/o F with DM2 HTN 3vCAD DISEASE (s/p MI s/p RCA
stent in [**2110**]) EtOH and tobacco abuse DISEASE h/o depression/[**Hospital 9582**]
transferred to the [**Hospital1 18**] CCU on [**8-15**] from [**Hospital 487**] Hospital for
VF arrest DISEASE on [**8-14**] shocked in the field.

Pt was in her USOH until [**8-14**]. In the evening she cooked dinner
for her husband then watched a movie and went to bed. At around
1am she woke her husband up with substernal chest pain DISEASE . She
thook sublingual NTG which resolved the pain DISEASE immediately.
Approximately 15minutes later the patient again experience
chest pain DISEASE . Her husband called 911 and by the time he returned
to her side she began to slump in her chair and became
unconscious eyes Admission Date: [**2116-9-12**] Discharge Date: [**2116-9-22**]

Date of Birth: [**2069-1-3**] Sex: F

Service: MEDICINE

Allergies DISEASE :
IodineAdmission Date: [**2179-3-21**] Discharge Date: [**2179-3-26**]

Date of Birth: [**2114-2-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan

Attending:[**Last Name (NamePattern1) 293**]
Chief Complaint:
Hypotension DISEASE

Major Surgical or Invasive Procedure:
Right Internal Jugular Central Venous Catheter Placement [**2179-3-21**]
Tracheal Tube Change


History of Present Illness:
64 year-old gentleman with MMP history of lung cancer DISEASE s/p right
pneumonectomy in [**2174**] severe COPD DISEASE recently discharged from
[**Hospital1 18**] MICU [**2178-12-2**] s/p tracheostomy and [**Month/Day/Year 282**] placement after
admission for respiratory failure DISEASE due to pneumonia DISEASE now
re-admitted to [**Hospital1 18**] with hypotension tachycardia DISEASE and UTI DISEASE .
.

In the ED RIJ placed he was given 4L IVF and started on CTX.
CT head no ICH DISEASE CXR Admission Date: [**2117-7-15**] Discharge Date: [**2117-7-27**]

Date of Birth: [**2069-1-3**] Sex: F

Service: MEDICINE

Allergies DISEASE :
IodineAdmission Date: [**2189-7-15**] Discharge Date: [**2189-7-19**]

Date of Birth: [**2120-1-7**] Sex: M

Service: MICU KURLA

CHIEF COMPLAINT: Found down in setting of gastrointestinal
bleed.

HISTORY OF PRESENT ILLNESS: This is a 69-year-old male with
history of mental retardation with IQ of 60 peptic ulcer DISEASE
disease with a history of gastrointestinal bleed DISEASE and
guaiac-positive stools as well as asthma depression DISEASE with
psychotic seizures DISEASE and hospitalization for suicidal ideation DISEASE
with plan who was brought to the Emergency Room by Emergency
Medical Service after being found down by brother in pool of
red blood around face and mouth the morning of admission.

Brother reports has a history of falls over the last two to
three years ago but none recent. Was in usual state of
health until found bleeding DISEASE this morning. Says that his
brother was able to converse appropriately and en route to
hospital family reports that patient vomited black material
and shortly became obtunded.

In the Emergency Room vital signs included a temperature of
96.1 F a pulse of 112 a blood pressure of 170/65
respiratory rate of 12 and he was satting 94%. The patient
was somnolent to following commands. Orogastric lavage was
done with return of coffee grounds which cleared with 400 cc.
Patient was intubated thereafter for airway protection and
transfused two units of red cells for an initial hematocrit
of 31 and bolused with three liters of normal saline. He was
transiently hypotensive DISEASE to the systolic 80s after intubation
in the setting of some rigors DISEASE with a tympanic temperature of
92. He was bolused with warm fluids and started on a warming
blanket. He also received Clindamycin for question
aspiration.

PAST MEDICAL HISTORY:
1. Mental retardation IQ of 60.
2. Chronic constipation DISEASE with multiple admissions.
3. Hypercholesterolemia.
4. Asthma.
5. Hiatal hernia.
6. GERD with Barrett's esophagus DISEASE as well as peptic ulcer DISEASE
disease with history of UGVI and history of guaiac-positive
stools.
7. History of [**Female First Name (un) 564**] esophagitis DISEASE .
8. Depression with psychotic DISEASE features and suicidal ideation DISEASE .
9. Iron-deficiency anemia DISEASE .
10. BPH status post TURP.
11. DJD DISEASE .
12. Nasal polyps DISEASE .

PAST SURGICAL HISTORY:
1. Hernia repair bilaterally.
2. Wedge resection of benign right apical lung mass.
3. TURP.

SOCIAL HISTORY: Patient lives with brother who also has
mental retardation. No tobacco alcohol or drugs.
Independent with activities of daily living. Health care
proxy is [**Name (NI) 3065**] [**Name (NI) **] at [**Telephone/Fax (1) 9603**].

MEDICATIONS ON ADMISSION:
1. Accolate 20 b.i.d.
2. Lipitor 10.
3. Carafate 1 gram b.i.d.
4. Celexa 80 q. h.s.
5. Colace 100 t.i.d.
6. Fleet enema.
7. Flovent inhaler.
8. Lactulose b.i.d.
9. Lasix 10 b.i.d.
10. Protonix 40 q.d.
11. Serax 30 h.s.
12. Serevent MDI.
13. Vitamin C.
14. Volmax 4 mg b.i.d.
15. Wellbutrin 150 mg b.i.d.
16. Zyprexa 2.5 mg b.i.d. and 2 mg q. h.s.
17. Niferex 150 b.i.d.

ALLERGIES: He has no known drug allergies DISEASE .

PHYSICAL EXAMINATION: Initial physical exam was significant
for the patient being intubated disheveled with some
rigors. Pupillary exam was normal. Patient was in a
C-collar. He had poor air movement bilaterally with
inspiratory and expiratory wheezes throughout. Cardiac and
abdominal exams were unremarkable. Toes were downgoing. He
was unresponsive to voice. He had no gag reflex but did have
corneal reflexes. Gastrointestinal fellow exam in ER showed
a finding of brown stool which was heme negativeAdmission Date: [**2192-1-17**] Discharge Date: [**2192-1-23**]

Date of Birth: [**2120-1-7**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
dyspnea DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname **] is a 72 year old male with history of mental
retardation [**Known lastname **] (see below) who presented to [**Hospital1 18**] from his
adult day care center yesterday after having increasing dyspnea DISEASE
and wheezing DISEASE despite increased nebulizer use. Patient also noted
to have non-productive cough DISEASE no other URI symptoms. No
headache myalgias DISEASE no known fevers DISEASE at home. No known sick
contacts but attends day program.
.
In ER patient was uable to perform peak flow and was given
continuous nebs then peak flowAdmission Date: [**2123-4-8**] Discharge Date: [**2123-5-1**]

Date of Birth: [**2048-8-27**] Sex: F

Service: [**Year (4 digits) **]

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 6736**]
Chief Complaint:
Weakness lightheadedness DISEASE worsening hematuria DISEASE

Major Surgical or Invasive Procedure:
1. Left selective renal angiography - [**2123-4-8**] - Interventional
Radiology
2. Right percutaneous nephroureteral stent change - [**2123-4-14**] -
Interventional Radiology
3. Left antegrade ureteroscopy - [**2123-4-17**] - Dr. [**First Name (STitle) **] [**Name (STitle) **]
4. Aortogram Left internal and external iliac arteriograms -
[**2123-4-22**] - interventional radiology
5. Cystoscopy left ureteral stent removal - [**2123-4-23**] - Dr. [**First Name (STitle) **]
[**Name (STitle) **]
6. Right percutaneous nephroureteral stent removal placement of
right percutaneous nephrostomy tube bilateral ureteral balloon
occlusion bilateral antegrade nephrostograms.
7. Aortogram Left common internal and external iliac
arteriogram coil embolization of left internal iliac artery -
[**2123-4-24**] - interventional radiology
8. Placement of PICC line - [**2123-4-29**] - interventional radiology
9. Left common internal and external iliac arteriogram -
[**2123-4-30**] - interventional radiology


History of Present Illness:
74 F with h/o colon cancer DISEASE s/p chemotherapy and pelvic radiation

c/b colovesical fistula and colostomy. She also has a history
of chronic bilateral ureteral obstruction DISEASE for which she is
managed by bilateral percutaneous nephroureteral stents that are
periodically changed. She developed hematuria DISEASE around the time of
L percutaneous nephroureteral stent change [**2123-3-30**] and underwent
selective angiography of left kidney with selective embolization
of a left renal angiodysplasia DISEASE [**2123-4-1**]. Her Hct on discharge
was 28.

Tonight she felt hematuria DISEASE worsened Admission Date: [**2141-7-29**] Discharge Date: [**2141-8-1**]

Date of Birth: [**2088-8-13**] Sex: M

Service: CCU

CHIEF COMPLAINT: Syncope DISEASE .

HISTORY OF PRESENT ILLNESS: This is a 52 year old gentleman
with a past medical history significant for transient
complete heart block DISEASE who presented through the Emergency
Department status post a syncopal DISEASE episode at home. The
patient reports that on the morning of admission he had an
episode of dizziness DISEASE and a feeling that his head was very
heavy while he was breathing. The patient got up to use the
bathroom and had a syncopal DISEASE episode while arising from the
toilet. The patient struck the left side of his head and had
loss of consciousness DISEASE for a few seconds. The patient then
presented to the Emergency Department for further evaluation.

The patient reports that the incident at home was not
associated with shortness of breath DISEASE but does report very dull
pain DISEASE / dull pressure sensation in his chest.

In the Emergency Department the patient had several more
Admission Date: [**2108-6-29**] Discharge Date: [**2108-7-3**]

Date of Birth: [**2049-3-3**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Atenolol / Metoprolol

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain DISEASE

Major Surgical or Invasive Procedure:
[**2108-6-29**] Coronary bypass grafting x 5: Left internal mammary
artery to left anterior descending coronary arteryAdmission Date: [**2167-11-16**] Discharge Date: [**2167-11-21**]

Date of Birth: [**2096-11-19**] Sex: M

Service:

HISTORY OF PRESENT ILLNESS:
Patient was a 70-year-old male with a 10 year history of
external retrosternal chest discomfort that occurred
periodically while exercising. The patient however is very
active and prior to having shoulder surgery in [**5-24**] was
biking up to 25 miles a day. Because of the shoulder
surgery the patient's level of physical activity has since
then been diminished.

The patient was scheduled for an exercise stress test on
[**2167-10-16**] where he exercised for 11 minutes and achieved 84%
of his predictable heart rate. The patient had some
substernal chest discomfort and had electrocardiogram changes
with ST segment depressions of [**12-23**].5 mm inferolaterally.
Imaging revealed a mild partially reversible septal defect.
The patient's ejection fraction of 67%. The patient was
referred to the [**Hospital1 69**] for an
outpatient cardiac catheterization.

PAST MEDICAL HISTORY:
1. Hypertension DISEASE .
2. Loss of hearing of left ear DISEASE due to scarlet fever DISEASE (hearing
aid).
3. Decreased testosterone.
4. Pituitary microadenoma DISEASE - 6 mm.

PAST SURGICAL HISTORY:
1. On [**5-/2167**] right rotator cuff repair.
2. Mastoid surgery in the past.

ALLERGIES:
No known drug allergies DISEASE .

MEDICATIONS:
1. Aspirin 81 mg po q day.
2. Norvasc 5 mg po q day.
3. Testosterone injections every three weeks.

HOSPITAL COURSE:
Patient was admitted to the [**Hospital1 188**] on [**2167-11-16**] for cardiac catheterization. He was found
to have left main and multivessel disease DISEASE and Cardiothoracic
Surgery was consulted. Decision was made to take the patient
for coronary artery bypass graft.

The patient underwent bypass surgery on [**2167-11-17**] with his
left internal mammary being grafted to the left anterior
descending artery and with saphenous vein graft to the PDA
the OM and the diagonal.

The patient was thereafter transferred to the SICU for
continued monitoring. The patient had an uncomplicated
postoperative course and was transferred to the
Cardiothoracic Surgery floor on postoperative day #1. The
patient's pain DISEASE was well controlled. Physical therapy was
initiated and the patient was able to tolerate activity
well.

On postoperative day #3 the patient complained of epigastric
discomfort aggravated by talking. The patient had a benign
abdominal examination and was still passing flatus although
he had not yet had a bowel movement. The pain DISEASE was not
anginal DISEASE in type. Decision was made to order the serum
amylase test to evaluate for pancreatitis DISEASE . The test was
negative with an amylase coming back at 40.

By postoperative day #4 the patient was deemed stable for
discharge to home. At the time of discharge the patient had
scratchy voice that was suspected to be caused by his
intubation during surgery. The patient was instructed to
contact Dr. [**Last Name (STitle) 70**] if his voice quality did not improve in
the days following discharge.

DISCHARGE CONDITION:
Stable.

DISCHARGE MEDICATIONS:
1. Enteric DISEASE coated aspirin 325 mg po q day.
2. Colace 100 mg po bid.
3. Lasix 20 mg po bid.
4. Potassium chloride 20 mEq po bid.
5. Motrin 400 mg po q6-8h prn.
6. Dilaudid 1-2 tablets po q4-6h prn (The patient did not
require beta blockade because he had a resting heart rate in
the 60s-70s).

FOLLOWUP:
The patient is to followup with Dr. [**Last Name (STitle) 70**] six weeks
following discharge. The patient is asked to followup with
his primary care physician [**Last Name (NamePattern4) **] [**1-26**] weeks following discharge.



[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]

Dictated By:[**Name8 (MD) 997**]

MEDQUIST36

D: [**2167-11-22**] 12:29
T: [**2167-11-25**] 06:53
JOB#: [**Job Number 9629**]
Admission Date: [**2110-3-31**] Discharge Date: [**2110-4-10**]


Service: Cardiac Surgery

NOTE: Date of discharge pendingAdmission Date: [**2112-6-26**] Discharge Date: [**2112-7-1**]

Date of Birth: [**2043-4-18**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional dyspnea DISEASE

Major Surgical or Invasive Procedure:
[**2112-6-27**] Aortic valve replacement (23mm St. [**Male First Name (un) 923**] Regent mechanical
valve)

History of Present Illness:
69 year old gentleman with a complex past medical history who
has known coronary artery disease DISEASE status post angioplasty and
aortic stenosis DISEASE followed by serial echocardiogram. He has
recently noticed increased dyspnea DISEASE on exertion. Echo earlier
this year showed severe aortic stenosis DISEASE with [**Location (un) 109**] 0.76cm2. He was
referred for a cardiac catheterization which revealed no
significant coronary disease DISEASE and mild aortic stenosis DISEASE . He
presents now to see if his dyspnea DISEASE is related to his aortic
valve disease DISEASE and if he should proceed with surgery. Of note
pulmonary function testing and a chest CT scan were not
suggestive of any disease process which may be responsible for
his exertional dyspnea DISEASE .

Past Medical History:
Aortic stenosis DISEASE
Hypertension DISEASE
Dyslipidemia DISEASE
Diabetes DISEASE type 2
Paroxysmal atrial fibrillation DISEASE - Cardioversion x2
B cell lymphoma chemo DISEASE and xrt
Prostate CA
Herpes Zoster DISEASE
Lung CA
Bursitis
Urinary incontinence DISEASE s/p artificial sphincter
Spinal stenosis
S/P right lower lobectomy [**3-/2107**]
S/P fatty tumor removal from his back
Prostate cancer DISEASE s/p resection and radiationAdmission Date: [**2188-3-9**] Discharge Date: [**2188-3-19**]

Date of Birth: [**2108-7-24**] Sex: M

Service: SURGERY

Allergies DISEASE :
Latex

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Reversal of Colostomy

Major Surgical or Invasive Procedure:
[**2188-3-10**]: Exploratory laparotomy and takedown of Hartmann's
procedure.


History of Present Illness:
This is a 79-year-old male who underwent an abdominal aortic
aneurysm DISEASE repair ([**4-18**]) which was complicated by ischemic colon
requiring colostomy/hartmanns procedure ([**2187-4-26**]) complicated by
stomal prolapse 4-5 DISEASE cm wide presents for reversal of colostomy.
Pt was scheduled for barium enema [**2-20**]. Results show normal
pouchogram. No evidence of leak. However pt is severely bothered
by stomal prolapse DISEASE .

Pt has been stable with no new medical issues since discharge.
Pt does have intermittent asymptomatic atrial fibrillation DISEASE for
which he normally takes Coumadin. Pt has had a few episodes of
syncope DISEASE in the last year associated with low blood pressures DISEASE .
Last syncopal DISEASE episode was [**2187-12-13**]. Pt stopped Coumadin([**3-2**])
Plavix ([**3-2**]) and apsrin ([**3-1**]) 4-5 days prior to surgery. Pt
was cleared for surgery by cardiology (Dr. [**Last Name (STitle) **]. Recent
ECHO ([**2-21**]) shows EF 50-55% with moderate mitral regurgitation DISEASE
and only mild LA enlargement DISEASE .
Review of symptoms is negative
Patient was admitted on [**2188-3-7**] however wanted to delay the
surgery till [**2188-3-10**]. He was discharged on Lovenox and returns
today for preop eval. Patient reports no new changes in medical
condition over last two days.


Past Medical History:
AAA repair
bilat renal stents [**2187-4-24**]
L hemicolectomy with Hartmanns/colostomy [**2187-4-26**] debridement of
peripancreatic necrosis DISEASE [**2187-5-25**]
HTN DISEASE
Hypercholesterolemia DISEASE
DM DISEASE
Afib DISEASE (off coumadin)
claudication DISEASE
vericose veins
GERD
anxiety DISEASE

Social History:
pt denies ETOH cigarettes or illicit drug use. lives with wife.


Family History:
N/C

Physical Exam:
GEN: NAD AOX3
Cards: RRR faint holosystolic murmur DISEASE [**2-15**] distant heart sounds
Lungs: CTAB
Abd: soft NT non distended. colostomy bag brown stool
Skin: around colostomy no calor/rubor/tumor/dolor or other signs
of infection DISEASE .
Ext: no edema DISEASE



Pertinent Results:
On Admission: [**2188-3-9**]
WBC-7.5 RBC-3.72* Hgb-12.1* Hct-34.2* MCV-92 MCH-32.6*
MCHC-35.5* RDW-13.7 Plt Ct-152
PT-13.3 PTT-27.6 INR(PT)-1.1
Glucose-91 UreaN-24* Creat-1.3* Na-138 K-4.6 Cl-102 HCO3-29
AnGap-12
Calcium-9.1 Phos-3.2 Mg-2.0
At Discharge: [**2188-3-18**]
WBC-10.2 RBC-3.12* Hgb-9.9* Hct-27.9* MCV-90 MCH-31.8 MCHC-35.5*
RDW-14.3 Plt Ct-256
PT-23.2* PTT-32.7 INR(PT)-2.2*
Glucose-111* UreaN-24* Creat-1.3* Na-135 K-3.9 Cl-102 HCO3-28
AnGap-9 DISEASE
Calcium-8.2* Phos-2.5* Mg-2.0

Brief Hospital Course:
79 y/o male who was admitted for pre-op heparinization and was
taken to the OR for ex lap with reversal of his Hartmans by Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Per operative note the abdomen was free of
adhesions DISEASE . The ostomy was successfully taken down and the
abdomen was primarily repaired without mesh. He was extubated in
the OR and transferred to the PACU in stable condition.

ASA and plavix were restarted on POD 1. A heparin drip was
started on POD 2. Coumadin was restarted on pod 2 once PTT was
in range. INR was monitored daily.
On POD 3 he developed a rapid heartbeat. 12 lead EKG showed
Atrial fibrillation DISEASE with rapid ventricular response. The patient
was asymptomatic however the Afib DISEASE did not respond to 5 mg IV
Lopressor x 3 doses therefore he was transferred to the SICU for
a diltiazem drip. Cardiac enzymes were unremarkable.

Cardiology was consulted and recommended uptitrating the
metoprolol as BP allowed and titrating off the IV diltiazem.
This was done with conversion to PO meds over 2 days with the
diltiazem drip stopped. He transferred back to the
medical/surgical floor.

He was only off the diltiazem one day when he was noted to
again have atrial fibrillation DISEASE . The diltiazem PO was restarted
controlling his rate. A cardiology follow up with Dr. [**Last Name (STitle) **]
was arranged for [**3-26**] to followup the change in regimen as well
as restarting the INR monitoring once he is discharged to home.

He developed diarrhea DISEASE on POD 6 and was found to be C. Diff
positive. Six weeks of PO Vanco was recommended by ID. Patient
does have a prior history of C diff infection DISEASE . He was started on
vancomycin 250mg q 6 hours x 10 days. This was started on [**3-17**].
Vanco then would decrease to 150mg q 6 hours for 1 week then
150mg twice daily for 1 week then 150mg qd x 1 week then 150mg
every other day for 1 week then every 3 days x 1 week.

He was screened for MRSA (nasal and rectal)while in the SICU and
found to be positive.

The wound incision was clean/dry/intact. The open area at the
site of the ostomy takedown required a small saline wet to dry
packing dressing [**Hospital1 **]. This area appeared clean.

Coumadin was started at 5mg qd on [**3-12**]. He received this thru
[**3-16**]. INR increased to 4.1 on [**3-17**]. Coumadin was held on [**3-17**]. On
[**3-18**] 3mg of coumadin was given for INR of 2.2. On [**3-19**] INR was
1.5. Coumadin 5mg daily was ordered. This was his home dose. He
should have daily INRs until stabilized on home dose.

Patient was evaluated by PT. He initially had some orthostatic DISEASE
hyppotension DISEASE but this resolved and he was ambulating using a
walker. Rehab was recommended to increase endurance progress
distance ambulated and maximize function. A rehab bed was
available at [**Hospital **] Rehab Hospital. He was transferred there
in stable condition.


Medications on Admission:
Asprin 81 mg (stopped Sat [**3-1**])
Plavix 75 mg QD (stopped sun [**3-2**])
Coumadin 5mg QD (stopped Sat [**3-1**])
gabapentin 300mg QD
lisinopril 5mg QD
metoprolol 50mg QD
simvastatin 20mg QD


Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet Chewable Sig: One (1) Tablet Chewable
PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
4. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: inr daily until stable.
8. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day.
9. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: then 150 QID x1 week then 150mg BIDx1 wk
then 150mg Qday x1 wk then 150 QOD x1 wk then 1 week of Q3days.
.
10. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection ASDIR (AS DIRECTED): qid
see printed scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
s/p Hartmanns reversal
Atrial fibrillation DISEASE
C.difficile


Discharge Condition:
Stable/Fair


Discharge Instructions:
Please call Dr[**Name (NI) 670**] office at [**Telephone/Fax (1) 673**] for fever DISEASE Admission Date: [**2179-4-12**] Discharge Date: [**2179-4-15**]

Date of Birth: [**2114-2-8**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / Ativan

Attending:[**First Name3 (LF) 297**]
Chief Complaint:
altered mental status and hypotension DISEASE

Major Surgical or Invasive Procedure:
picc line and central access


History of Present Illness:
65 year-old gentleman with multiple medical problem including
history of lung cancer DISEASE post right pneumonectomy in [**2174**] severe
COPD DISEASE post tracheostomy and [**Year (4 digits) 282**] placement(respiratory failure DISEASE
due to pneumonia DISEASE ) recently admitted to [**Hospital1 18**] for urosepsis DISEASE now
presenting yet again with hypotension DISEASE and altered mental status.

Patient unable to give a history at this time so obtained from
records. Pt was admitted to [**Hospital1 **] on [**3-26**] after an admission
at [**Hospital1 18**] for a Klebsiella UTI and hypotension DISEASE . Since his
admission there the pt has been alert and getting out of bed to
the commode with assistance. On [**4-11**] the pt became lethargic
and then gradually unresponsive. On [**4-12**] his BP decreased to
60 over palp and the pt was noted to be diaphoretic. He received
a 500 cc bolus with an increase in his BP to 90/40. He remained
unresponsive during this time. ABG showed 7.265/92.7/82 on an
FiO2 of 0.50 with a temperature of 99.4. Of note pt's triple
lumen was placed [**2179-3-21**].
.
Wife later arrived at the hospital and was able to provide
additional history. She reports that he had been doing very well
until Friday. They were working on weaning him and he was able
to be on the trach mask for 1-2 hours at a time. However on
Friday the pt felt mildly more SOB per his report. He was
maintained exclusively on the vent over the rest of the weekend.
Yesterday the pt's wife reports that he looked Admission Date: [**2116-7-6**] Discharge Date: [**2116-7-13**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
epigastric painvomitting


Major Surgical or Invasive Procedure:
none

History of Present Illness:
Patient is a 85 y/o F with Myelodysplastic DISEASE syndrome/RAEB who
presented to an OSH ED with complaints of epigastric pain DISEASE N/V.
She was found to have leukocytosis DISEASE to 28000 and underwent a CT
abdomen. The CT revealed bilateral lower lobe pneumonia DISEASE . She was
given 500mg Levaquin and transfered to [**Hospital1 18**]. At [**Hospital1 18**] CXR
revealed multifocal air space opacities DISEASE . She was given
Ceftriaxone and Vancomycin. She remained HD stable requiring 3
L oxygen by N/C. Also noted to have a Troponin of .44 with a neg
CK and a lactate of 3.8. Currently she complains of continued
epigastric pain DISEASE but denies SOB cough chest pain fever DISEASE
diarrhea nausea vomiting dysuria DISEASE .

ROS: As mentioned above the patient had pain DISEASE in abdomen since [**34**]
hours before admission. It was in right as well as left upper
quadrant no radiation moderately severe did not change with
coughing. She did not have it now. However there is tenderness DISEASE
to palpation on exam in right upper quadrant more paraumbilical
than subcostal. She did not complain of any nausea DISEASE (which she
had on admission) vomitting today. She gives h/o diarrhea DISEASE .
The pt did not have any difficulty or pain DISEASE in swallowing no
sensation of food getting stuck in the food pipe.
No complaints of fever chills sore DISEASE throat. She gives h/o mild
cough DISEASE since last 7 days but no sputum production.
No h/o chest pain DISEASE . H/o SOB since last 7 days.


Past Medical History:
- e
Name: [**Known lastname 395**] [**Known firstname **] Unit No: [**Numeric Identifier 9675**]
Admission Date: [**2152-2-9**] Discharge Date: [**2152-2-14**]


Service: Medicine

HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old male with
Parkinson's disease dementia DISEASE history of aspiration in the
past who was in his usual state of health until the morning
of [**2-9**] when he was noted to be unable to get out of bed
in the morning secondary to profound fatigue DISEASE . He also noted
mild shortness of breath and cough DISEASE productive of yellowish
brown sputum. There were no fevers DISEASE or chills DISEASE no pleuritic DISEASE
chest pain DISEASE . There was no witnessed aspiration event. There
were no recent sick contacts but the patient goes to the
[**Hospital3 **] Day Care program. Denied falls head
trauma DISEASE or loss of consciousness DISEASE . The patient was found by
VNA and taken to [**Hospital1 69**]
Emergency Room where chest x-ray was consistent with right
lower lobe pneumonia DISEASE . He was hemodynamically stable but then
was noted to have hypotensive DISEASE episodes to 70/palp with
bradycardia DISEASE heart rate in the 30's. There was no response
to Atropine. He was given intravenous fluids with a good
blood pressure response and then admitted to the medical
Intensive Care Unit.

PAST MEDICAL HISTORY: Parkinson's dementia depression DISEASE
anxiety DISEASE coronary artery disease DISEASE status post myocardial
infarction DISEASE in [**2104**] squamous cell carcinoma DISEASE of the vocal
cords status post excision and XRT hypertension spinal
stenosis BPH DISEASE status post TURP.

MEDICATIONS: Sinemet 25/100 po tid Diltiazem 180 mg po q d
Aricept 10 mg po q d Proscar 5 mg po q d Multivitamin one
tablet po q d Beconase eyedrops and Clotrimazole.

ALLERGIES: No known drug allergies DISEASE .

SOCIAL HISTORY: Lives in elder housing very supportive
family. Daughter's telephone number is [**Telephone/Fax (1) 9676**]. Her
cell phone is [**Telephone/Fax (1) 9677**].

PHYSICAL EXAMINATION: Vital signs temperature 98.9 blood
pressure 137/75 pulse 70 respirations 20 and oxygen
saturation 91% on room air. In general he was alert at times
but at other times confused. HEENT: Conjunctiva were moist
no pallor. Pupils were 2 mm bilaterally reactive. Tongue
was dry. Oral cavity was dry. There is a right facial
droop. Extraocular motions are full. The palate was
symmetric and elevated bilaterally. Sternocleidomastoid and
trapezius were full strength bilaterally. Chest bilateral
wheeze and basilar rhonchi DISEASE bilaterally. Cardiac exam was
normal S1 and S2 regular rate and rhythm and no murmurs.
Abdomen was soft and nontender with positive bowel sounds.
There is a large right sided inguinal hernia DISEASE that was
partially reducible. The extremities were warm and pulses
were fully palpable distally. Neuro exam 5-/5 strength
globally.

LABORATORY DATA: On admission Chem 7 sodium 140 potassium
4.6 chloride 102 CO2 27 BUN 27 creatinine 1.5 and glucose
148. CBC white cells 19.8 differential 81% neutrophils 7%
bands 2% lymphocytes and 10% monocytes. Hematocrit 39.9 and
platelet count 291000. Urinalysis trace blood 30 protein
[**2-1**] red blood cells rare bacteria 0-2 epithelial cells.
Chest x-ray right lower lobe pneumonia DISEASE . EKG normal sinus
rhythm right bundle branch block left ventricular strain.

Blood culture no growth. Urine culture no growth. Sputum
culture poor sample contaminated with oropharyngeal flora.

IMPRESSION: [**Age over 90 **]-year-old male with Parkinson's disease DISEASE
coronary artery disease DISEASE history of vocal cord cancer DISEASE
presents with pneumonia DISEASE and hypotension DISEASE .

HOSPITAL COURSE:
1. Infectious disease: The patient's pneumonia DISEASE was treated
with Levaquin Vancomycin and Flagyl. He improved
significantly and was ultimately changed to oral Levaquin and
Flagyl. No definitive pathogen was every identified.

2. Pulmonary: The patient improved dramatically with
antibiotics as stated above. Albuterol and Atrovent nebs
were used for several days but were ultimately not needed by
the end of his hospital stay. Chest PT was done. His oxygen
saturation improved to 95-97% on room air.

3. Cardiovascular: It was assumed that the patient's
hypotension DISEASE and bradycardia DISEASE were representative of a brief
episode of sepsis DISEASE . This resolved with IV fluids and
antibiotic therapy. Initially his anti-hypertensives were
held but there were added back once he became hemodynamically
stable.

4. Renal: The patient has a mild renal insufficiency DISEASE of a
prerenal DISEASE etiology. This resolved completely with IV fluids.
His baseline creatinine is 1.5.

5. Prophylaxis: The patient was given subcu Heparin and
Protonix for prophylaxis. He was able to ambulate well on
the last day of admission and the Heparin was discontinued.

In terms of disposition physical therapist felt that the
patient was safe for discharge home. Extensive home services
were arranged.

DISCHARGE STATUS: He was discharged to home.

DISCHARGE CONDITION: Good.

DISCHARGE MEDICATIONS: Sinemet 25/100 one tablet po tid
Cardizem CD 180 mg po q d Aricept 10 mg po q d Proscar 5 mg
po q d Multivitamin one po q d Beconase one spray per
nostril [**Hospital1 **] Ophthalmic solution 3.03% one drop each eye q d
Lotrisone cream topically to the back of legs [**Hospital1 **]
Levofloxacin 250 mg po q d until [**2-25**] Metronidazole 500
mg po tid until [**2-25**].

DISCHARGE DIAGNOSIS:
1. Pneumonia DISEASE presumed secondary to aspiration.
2. Parkinson's disease DISEASE .
3. Hypotension.
4. Bradycardia.




[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9678**] M.D. [**MD Number(1) 9679**]

Dictated By:[**Name8 (MD) 2734**]

MEDQUIST36

D: [**2152-6-20**] 19:16
T: [**2152-6-24**] 15:47
JOB#: [**Job Number 9680**]














Admission Date: [**2138-7-14**] Discharge Date: [**2138-7-28**]

Date of Birth: [**2059-4-21**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Difficulty swallowing.

Major Surgical or Invasive Procedure:
PEG placement.


History of Present Illness:
This is a 79 y/o male patient with multiple system atrophy DISEASE
(aggresive form of Parkinsons DISEASE ) HTN DISEASE prostate ca s/p XRT who was
initially admitted to neurology service on [**7-14**] for dysphagia DISEASE
secondary to rapid deterioration of MSA and PEG placement. PEG
placement successful but after patient had sudden Hct drop and
on CT scan was found to have right RP and thigh bleed hematoma DISEASE
unknown etiology transferred to MICU. Vascular consulted and
felt surgery and angio no indicated at present time as patient
would require intubation. Patient was transfused a total of 9
units of blood while in the MICU. Patient last blood transfusion
was on [**2138-7-25**] in the am and Hct has been stable. For the past
few days patient neurologic function has become worse where
patient very stiff. Neurology following patient for management
of MSA. Patient also noted to be hypernatremic DISEASE in the MICU and
is being given free water bolus through PEG tube. During
hospital course patient had thrombocytopenia DISEASE as well HIT DISEASE sent
which came back negative plt count starting to improve. He
continue to spike low grade fevers DISEASE patient pan-cultured with no
source of infection DISEASE found CXR negative.


Past Medical History:
1.)Multisystem atrophy DISEASE
2.)HTN
3.)Prostate CA s/p XRT
4.)Cervical radiculopathy DISEASE
5.)Hypercholesterolemia


Social History:
Pt lives with wife and is cared for by multiple aides. He is
totally depedent for adl's. Quit tobacco 30yrs ago.


Family History:
No neuro disease DISEASE

Physical Exam:
t 98.4 bp 112/59 hr 104 rr 19 spo2 97%ra
gen- chronically ill appearing elderly male in nad
cv- tachy but reg no m/r/g
pul- moves air well minimal bibasilar rales DISEASE
abd- peg in place soft nt nd nabs
back- no sacral edema DISEASE no bruising DISEASE
extrm- 1Admission Date: [**2183-3-12**] Discharge Date: [**2183-3-21**]

Date of Birth: [**2141-5-14**] Sex: F

Service:

CHIEF COMPLAINT: Mrs. [**Known lastname 5655 DISEASE **] is a 41-year-old woman with a
history of systemic lupus erythematosus hypertension DISEASE and
BOOP DISEASE who came to the Emergency Department on [**2183-3-12**]
for cough DISEASE of two weeks duration and subsequently went into
hypoxic respiratory arrest DISEASE was intubated and transferred to
the Medical Intensive Care Unit.

HISTORY OF PRESENT ILLNESS: Over the two weeks prior to
admission Mrs. [**Known lastname 5655**] complained of increasing shortness DISEASE of
breath with a cough DISEASE productive of yellow sputum flecked with
blood. She denied any chills fever chest pain DISEASE or headache DISEASE .
Shortly before admission she was unable to walk more than
eight feet without having to rest and catch her breath. She
decided to come to the Emergency Department when she was
unable to walk up a flight of stairs without extreme
shortness of breath DISEASE .

While at the Emergency Department Mrs. [**Known lastname 5655 DISEASE **] got up to go
to the bathroom and on her return to her stretcher
experienced a hypertensive DISEASE crisis with systolic blood
pressure in the 190s and a heart rate greater than 140. She
became tachypneic short of breath confused and pulse
oximetry could not be obtained. She continued to be very
short of breath on 100% nonrebreather. She was intubated for
presumed respiratory failure DISEASE and transported to the Medical
Intensive Care Unit.

PAST MEDICAL HISTORY:
1. Systemic lupus erythematosus DISEASE diagnosed in [**2173**] with
AWA/ds-DNA/anti-[**Doctor Last Name **] positivity.
2. Lupus nephritis DISEASE - membranoproliferative DISEASE
glomerulonephritis DISEASE .
3. Hemolytic anemia DISEASE .
4. Thrombocytopenia.
5. Lupus cerebritis.
6. Lupus peritonitis DISEASE [**2179-1-6**].
7. Pleuritis.
8. Arthritis.
9. Raynaud's syndrome DISEASE .
10. BOOP DISEASE in [**2179-9-6**].
11. Hypertension DISEASE .
12. Salmonella bacteremia DISEASE in [**2182-7-6**].
13. TTP DISEASE - HUS DISEASE .
14. Membranous glomerulonephritis DISEASE with a necrotizing DISEASE
component and focal crescent formations mixed Type III/V
lupus erythematosus DISEASE .

SOCIAL HISTORY: Patient lives in [**Location 669**] with her brother.
She works part time as a tax accountant. She has a negative
tobacco history. She stopped drinking alcohol in [**2170**]. She
denies any other drug use. She is not currently sexually
active.

FAMILY HISTORY: The patient's mother died of lupus DISEASE at the
age of 47. She does not know her father well and is unable
to report on his health history. She has seven brothers and
sisters. Two of her brothers have alcoholism DISEASE . One sister
has insulin dependent diabetes mellitus DISEASE . There is no
significant family history of cancer asthma DISEASE or heart
disease.

ALLERGIES: Haldol - acute dystonic reaction DISEASE . Sulfa - hives
and shortness of breath DISEASE . Biaxin.

MEDICATIONS ON ARRIVAL AT THE EMERGENCY DEPARTMENT:
Lopressor 50 mg b.i.d. Zestril 5 mg q.d. prednisone 5 mg
q.d. aspirin 81 mg q.d. Lipitor 20 mg q.d. Prilosec 20 mg
q.d. Nephrocaps.

REVIEW OF SYSTEMS: Chronic constipation DISEASE treated with
Colace. Joint pain DISEASE significantly worse in winter time with
Raynaud DISEASE 's. No history of chest pain DISEASE or palpitations DISEASE .

PHYSICAL EXAM DISEASE ON ADMISSION TO THE MEDICAL INTENSIVE CARE
UNIT: General: intubated sedated middle-aged woman.
Vital signs: Blood pressure 140/90. Heart rate 130.
Temperature 99.1. Head eyes ears nose and throat: pupils
equal round and reactive to light. Sclerae are anicteric.
Neck supple no LAD. Chest: bilateral breath sounds
anteriorly. No wheezing DISEASE . Coarse bilateral breath sounds
throughout. Inspiratory crackles. Cardiovascular:
tachycardic rhythm no murmurs. Abdomen: soft nontender
nondistended normal active bowel sounds. Light brown guaiac
negative stool. Extremities: warm without edema DISEASE . Neuro:
Babinski DISEASE downgoing bilaterally. Sedated. Symmetric
reflexes.

LABORATORIES VALUES ON ADMISSION: White blood cell count
2.6 differential 57 neutrophils 2 basophils 25
lymphocytes 9 macrophages. Hematocrit 28.2 platelets
142000. MCV 82. Sodium 138 potassium 3.7 chloride 98
bicarbonate 28 BUN 27 creatinine 7.1 glucose 82.
Urinalysis: small amount of blood. Greater than 300 protein.
2 red blood cells 1 white blood cell 20 epithelial cells.

Electrocardiogram sinus tachycardia DISEASE . Rate 110 normal axis.
TWI V4 through V6 lead I.

HOSPITAL COURSE: While in the Emergency Department Mrs.
[**Known lastname 5655**] received nitroglycerin paste Lasix 80 mg intravenous
500 mg levofloxacin heparin per protocol Versed 1-2 mg per
hour via IV drip. After intubation in the Emergency
Department Mrs. [**Known lastname 5655**] received a bedside echocardiogram
which showed severe left ventricular systolic functional
depression DISEASE and a small loculated pericardial effusion DISEASE . Right
ventricular diastolic collapse was present consistent with
impaired filling and tamponade DISEASE . A chest x-ray at the time
showed congestive heart failure DISEASE with pulmonary edema DISEASE
although pneumonia DISEASE could not be excluded. An
electrocardiogram revealed T wave inversions laterally. Mrs.
[**Known lastname 5655**] then underwent CT angiography for pulmonary embolus DISEASE
which was negativeAdmission Date: [**2184-7-5**] Discharge Date: [**2184-7-11**]

Date of Birth: [**2141-5-14**] Sex: F

Service: BLUE GENERAL SURGERY

HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old
female with a history of systemic lupus erythematosus DISEASE and end
stage renal disease DISEASE on hemodialysis who presented to the
Emergency Department on [**2184-6-26**] with nausea vomiting DISEASE and
right upper quadrant abdominal pain DISEASE . The patient was seen
the evening prior in the Emergency Department for biliary
colic with 9 out of 10 pain DISEASE . Her liver function tests were
significant for elevated amylase and lipase. Ultrasound at
that time showed cholelithiasis DISEASE with no evidence of
cholecystitis DISEASE or biliary obstruction DISEASE . The patient was sent
home where she refrained from eating however returned to
the Emergency Department on the day of admission complaining
of nausea DISEASE and vomiting DISEASE of clear emesis DISEASE . Her abdominal pain DISEASE
decreased to 4 out of 10. The patient denied fevers DISEASE or
chills DISEASE . The patient had flatus and her last bowel movement DISEASE
was the morning prior to admission.

PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus DISEASE
diagnosed in [**2173**]. 2. Lupus nephritis DISEASE leading to end stage
renal disease DISEASE on hemodialysis for two years. 3. Hemolytic
anemia DISEASE . 4. Thrombocytopenia. 5. Raynaud's. 6.
Hypercholesterolemia DISEASE . 7. BOOP diagnosed in [**2179**]. 8.
Hypertension DISEASE . 9. Osteoporosis. 10. Cardiomyopathy (EF
equals 35 to 40%). 11. Lupus cerebritis DISEASE .

PAST SURGICAL HISTORY: Significant for a lung biopsy in
[**2179**].

ALLERGIES: Sulfa which causes shortness of breath DISEASE and
Biaxin.

SOCIAL HISTORY: No alcohol use. No tobacco use and no drug
use.

MEDICATIONS ON ADMISSION: 1. Prednisone 5 mg q.d. 2.
Atenolol 100 mg q.d. 3. Zestril 40 mg q day. 4. Lipitor
40 mg q.d. 5. Prilosec 20 mg q.d. 6. Phos-Lo 666 mg three
to four tablets each meal. 7. Folate 1 gram q.d. 8.
Nephrocaps.

PHYSICAL EXAMINATION: Vital signs temperature 97.6. Pulse
72. Blood pressure 193/103. Respiratory rate 20. O2 sat
100% on room air. In general she was a well appearing
African American woman in no acute distress. HEENT pupils
are equal round and reactive to light. Extraocular
movements intact. Anicteric sclera. Chest clear to
auscultation bilaterally. Cardiovascular regular rate and
rhythm. Normal S1 and S2 with a 2 out of 6 systolic ejection
murmur. Abdomen soft decreased bowel sounds DISEASE nondistended
tender in the right upper quadrant positive [**Doctor Last Name **] sign no
guarding or rebound tenderness. Rectal examination guaiac
negative. Pelvic examination no cervical motion tenderness DISEASE
per Emergency Department examination. Extremities warm no
clubbing cyanosis DISEASE or edema DISEASE . Left upper extremity AV fistula
with a palpable thrill.

LABORATORIES ON ADMISSION: White blood cell count 4
hematocrit 35.9 platelets 135 normal differential sodium
135 potassium 5.2 chloride 94 bicarb 29 BUN 52
creatinine 10.5 glucose 77 ALT 12 AST 12 alkaline
phosphatase 59 T bilirubin 0.3 amylase was 234 up from 180
lipase 148 which was up from 74. Urinalysis was positive
for bacteria and protein. Ultrasound revealed no gallbladder
wall thickening no pericholecystic fluid. It was positive
for gallstones DISEASE . No ductal dilatation and the common bile
duct equals 4 to 5 mm. Positive [**Doctor Last Name 515**] sign.

HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2184-6-26**] for gallstone DISEASE
pancreatitis DISEASE . The patient was made NPO except for
medications and pain DISEASE was controlled with morphine. She was
also begun on Cefazolin. Early in the a.m. of [**6-28**] the
patient experienced severe headaches DISEASE and was hypertensive DISEASE to
200/100. Initially the patient experienced some left facial
numbness DISEASE and twitching of all extremities. At this point
Lopressor intravenous was given with response noted morphine
was changed to Dilaudid DISEASE and .5 mg of Ativan was given with
resolution of symptoms. The patient went to dialysis later
that day where she was noted to have a generalized tonic
clonic seizure DISEASE lasting three to five minutes with a blood
pressure of 180/100. The patient was not dialyzed. The
seizure DISEASE occurred prior to dialysis. The patient denied ever
having seizures DISEASE or a seizure disorder DISEASE before. Neurology was
consulted and MRI and electroencephalogram were obtained at
their suggestion. MRI revealed no morphological abnormality
of the brain and no shift of intracranial structures. There
were a few nonspecific fossa of increased T2 signal in the
white matter of both cerebral hemispheres consistent with
small vessel infarct DISEASE . No abnormal intracranial DISEASE enhancement
was observed. The electroencephalogram was abnormal with a
burst of generalized slowing which is nonspecific for
cerebral dysfunction DISEASE but suggests the possibility of deep
midline brain dysfunction DISEASE .

The patient was begun on Dilantin 300 mg q.h.s. The patient
was dialyzed on both [**6-29**] and [**6-30**]. Due to the patient again
having twitching symptoms she was given an additional dose of
Dilantin prior to her discharge on [**7-1**] as she initially
refused to be loaded with the Dilantin on neurologies
request. The patient's abdominal examination remained stable
throughout her stay and was nontender to palpation on her
date of discharge. The patient's amylase and lipase trended
downward throughout her stay. The patient was tolerating a
low fat renal fluid restricted diet well on her discharge and
the patient is to return to the hospital for admission on
Monday [**2184-7-5**] after her dialysis treatment for a preop
admission for her laparoscopic cholecystectomy on [**2184-7-6**].
The patient will also follow up with neurology in clinic with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7431**]. Dr. [**Last Name (STitle) 7431**] provided the patient
with her card and information regarding making an
appointment.

MEDICATIONS ON DISCHARGE: 1. Keflex 500 mg po q 12 hours.
2. Dilantin 300 mg po q.h.s. 3. Prednisone 5 mg q.d. 4.
Atenolol 100 mg q.d. 5. Zestril 40 mg q.d. 6. Lipitor 40
mg po q.d. 7. Prilosec 20 mg q.d. 8. Phos-Lo 666 mg three
to four tablets each meal. 9. Folate 1 gram q.d. 10.
Nephrocaps.

CONDITION ON DISCHARGE: Stable.

DISCHARGE STATUS: Discharged to home without services.

DISCHARGE DIAGNOSES:
1. Resolved gallstone pancreatitis DISEASE .
2. New onset generalized tonic clonic seizure DISEASE .






[**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 4007**]

Dictated By:[**Last Name (NamePattern1) 7432**]

MEDQUIST36

D: [**2184-7-11**] 17:05
T: [**2184-7-13**] 14:07
JOB#: [**Job Number 7433**]
Admission Date: [**2184-10-14**] Discharge Date: [**2184-10-21**]

Date of Birth: [**2108-7-24**] Sex: F

Service: CT [**Doctor First Name 147**]

CHIEF COMPLAINT: The patient is a 76 year old woman with a
history of MI in the past now referred for outpatient
cardiac cath due to a positive stress test.

HISTORY OF PRESENT ILLNESS: The patient reports that she had
an inferior MI DISEASE in [**2172**]. She was treated at [**Hospital 4628**] Hospital
and did not have cardiac catheterization at that time. She
has done well since that time and reports that she is very
active occasionally still dances with her husband and
performs all activities of daily living independently.
Denies DISEASE any symptoms of chest pain DISEASE or dyspnea DISEASE . Also denies
claudication orthopnea edema lightheadedness DISEASE . Primary
care provider is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**] who she sees on a regular
basis. She was recently at his office for an annual stress
echo which was done on [**9-27**]. Patient exercised for
three minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol. EKG revealed
inferolateral changes. Echo revealed exercise induced
ischemia DISEASE in the LAD distribution evidence of an old inferior
MI. Resting ejection fraction was 35% to 45%. She has been
referred for outpatient cardiac cath.

PAST MEDICAL HISTORY: Significant for hypertension DISEASE
hypercholesterolemia DISEASE CAD status post MI.

PAST SURGICAL HISTORY: Significant for thyroid nodule
removal and cataract DISEASE surgery with lens implantation.

ALLERGIES: No known drug allergies DISEASE .

MEDICATIONS PRIOR TO ADMISSION: Aspirin 325 mg q.d. Zestril
5 mg q.d. Lopressor 50 mg b.i.d. Pravachol 20 mg q.d.
triamterene hydrochlorothiazide 37.5/25 mg three times per
week Synthroid 0.125 mg q.d.

LABORATORY DATA: White count 5.0 hematocrit 41.4 platelet
count 181. Sodium 141 potassium 4.3 chloride 102 CO2 34
BUN 15 creatinine 1.0. INR 1.1.

SOCIAL HISTORY: Married lives in [**Location 3146**] with her husband.
She does not have any children. Denies cigarette use.
Denies alcohol use.

FAMILY HISTORY: She has a brother and sister who have both
had coronary artery bypass grafting in the past.

PHYSICAL EXAMINATION: On the day of catheterization heart
rate was in the 50s sinus rhythm blood pressure 150/50
respiratory rate 20 O2 sat 100%. Neck had no bruits DISEASE . Lungs
were clear bilaterally. Heart S1 S2 no murmurs regular
rate and rhythm. Abdomen soft nondistended nontender.
Right groin with a hematoma oozing DISEASE no bruit. Dorsalis pedis DISEASE
2Admission Date: [**2101-2-10**] Discharge Date: [**2101-2-15**]


Service: MEDICINE

Allergies DISEASE :
Patient recorded as having No Known Allergies DISEASE to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Hyperglycemia DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Patient is an 86 y/o male with type II diabetes CAD CHF DISEASE EF
25% AVR CRI who presents to outpt cardiac clinic in reported
rapid atrial fibrillation DISEASE and hyperglycemia DISEASE . Patient was sent to
the ED and rapid afib resolved but patient found with blood
sugar Admission Date: [**2103-7-17**] Discharge Date: [**2103-7-18**]


Service: MEDICINE

Allergies DISEASE :
Bactrim

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory distress DISEASE

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is an 89 yo M with history of CAD s/p CABG CHF DISEASE secondary
to ischemic CMY with EF 25% Afib IDDM DISEASE who presents from his NH
today with acute onset shortness of breath DISEASE .
In the ED he was initially thought to be in acute heart
failure given that he was hypertensive DISEASE to the 170's so he was
given lasix 40mg IV x1 placed on a nitro gtt and bipap. CXR
revealed a large RLL consolidation so the patient was also
covered for HAP with vanco and zosyn DISEASE but only vanco given. Sats
were only 90% on BiPAP at 10/5 FiO2 0.50. Labs were significant
for a large bandemia lactate of 5.1 troponin 0.19 and mild
renal failure DISEASE . 10 units of regular insulin was given for a
fingerstick of 450. Because the patient is DNR/DNI (which was
reconfirmed by the ED with the patient's HCP) he was not
intubated and transferred to the MICU for further management.

Past Medical History:
Anterior MI in [**2088**] Cath showed LAD disease DISEASE
s/p LIMA to LAD [**2088**]
Aortic Valve Repair - porcine prosthesis for aortic Stenosis DISEASE
(valve area 0.9 in [**2088**]) Valve and LIMA done at same surgery
Atrial Fibrillation DISEASE
Tachy-Brady DISEASE syndrome s/p [**Company 1543**] sigma DDI pacemaker [**2100-7-18**]

Ischemic Cardiomyopathy DISEASE - EF 25%
Hypertension DISEASE
IDDM DISEASE
Dyslipidemia DISEASE .


Social History:
Social history significant as Mr. [**Known lastname 7435**] is a recent widow who
previously lived alone in [**Location (un) 4628**] but was most recently
discharged to a rehab facility. Has 5 children four of which
live close by. He used to work as a butcher. He denies any
history of smoking and drinks approximately one drink per night
but none since [**Month (only) 116**]. He denies any illicit drug use.


Family History:
His father died at the age of 63 from liver and rectal cancer DISEASE
colon ca. metastatic to liverAdmission Date: [**2191-2-23**] Discharge Date: [**2191-3-3**]

Date of Birth: [**2124-10-22**] Sex: M

Service: CARDIOTHORACIC

Allergies DISEASE :
Avandia / Lisinopril

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain DISEASE

Major Surgical or Invasive Procedure:
Cardiac Catherization [**2191-2-24**]
Coronary Artery Bypass Graft (off pump) x2 (Saphenous vein graft
-Admission Date: [**2157-12-1**] Discharge Date: [**2157-12-4**]

Date of Birth: [**2099-6-29**] Sex: M

Service: MEDICINE

Allergies DISEASE :
Morphine

Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest Pain DISEASE

Major Surgical or Invasive Procedure:
None


History of Present Illness:
The patient is a 58 year old male with a history of DM HTN
dyslipidemiaPVD CAD with history of MI who transfered for
cardiac catheterization for a question of NSTEMI in the setting
of infection DISEASE . As noted the patient has a history of CAD with
an MI in [**2152**] for which he PCI to RCA in [**2152**] at [**Hospital1 336**]. The
patient has not had any further chest pain DISEASE since his MI. He
reports a baseline exercise tolerance of 5 blocks limited by
fatigue.

The patinet was admitted to [**Hospital1 **] [**Location (un) 620**] on [**11-28**] after
presenting with complaints of N/V x 1 day. The patients wife
was [**Name2 (NI) 7450**] admitted a few days prior with similar GI
symptoms and was diagnosed with viral gasteroenteritis DISEASE . On
presentation the patient was found to be hypotensive DISEASE in the 80s
febrile DISEASE to 102.9 was treated with IVF and one dose of
CTX/azythro. The patinet denies any diahrea or bloody stool.
He had continued n/v fever DISEASE and mild abdominal discomfort. He
was given continued IVF for supportive care in treatment of
presumed viral gastroenteritis DISEASE . His chest XR on admission was
unremarkable and he was satting on 96% on RA DISEASE .

On the evening of [**11-30**] at the OSH the patient developed acute
shortness of breath DISEASE . A CXR was obtained which was concerning
to the team for infiltrates. He was reportedly started on
CXR/Azythro but no documentation is available that he received
those antibiotics. he denies any recent productive cough DISEASE .
Blood cultures were also obtained. In this setting the patient
had ocmplaints of chest pain DISEASE similar but less intense than
prior MI. Described chest discomfort as sub-sternal chest
pressure scaled to [**4-23**] radiation to the shoulder. This chest
discomfort was relieved with SLNG. An EKG was obtained which
was concerning of a question of lateral ST depressions and
cardiac markers were elevated. The patient was started in
heparin palvix ASA and metprolol and was transfered to [**Hospital1 18**]
for cardiac catheterization.

While being transported the patient had continued chest pain DISEASE
which again was relieved with SLNG. He has been chest pain DISEASE free
since. In the holding area the patient had continued hypoxia DISEASE
requiring 100% NRB. He continued to be febrile DISEASE spiking a
temperature of 101.6 Cardiac catheterization was deffered and
the patient was admitted to the CCU for futher care.

On review of systems he denies any prior history of stroke DISEASE
TIA DISEASE deep venous thrombosis pulmonary embolism bleeding DISEASE at the
time of surgery myalgias DISEASE joint pains cough hemoptysis DISEASE black
stools or red stools. He denies recent fevers chills DISEASE or rigors.
He denies exertional buttock DISEASE or calf pain DISEASE . All of the other
review of systems were negative.

Cardiac review of systems is notable for the absence paroxysmal DISEASE
nocturnal dyspnea orthopnea ankle edema palpitations syncope DISEASE
or presyncope DISEASE .

Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS:: Diabetes Dyslipidemia Hypertension DISEASE
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: PCI to RCA at [**Hospital1 336**] in
[**2152**]
3. OTHER PAST MEDICAL HISTORY:
Sleep apnea DISEASE
Hiatal hernia DISEASE s/p surgical repair
Depression DISEASE
GERD DISEASE
Retinopathy DISEASE
Gastropathy
Nephropathy DISEASE (Baseline 1.6)
PVD DISEASE s/p status bilateral infrapopliteal revascularization
Critical PT lesion successfully treated with athrectomy and PTA.


Social History:
-Tobacco history: Not a current smoker Quit smoking: in the
[**2118**]
-ETOH: Does not drink alcohol
-Illicit drugs: None
-Retired courier married with one son.



Family History:
Father: previous MIs DISEASE

Physical Exam:
VS: T